APPLICATION FORM

Insurance KYC & Nominee Form

Please complete the information carefully. This local form does not submit or store your information online; use the completed form only when sharing it through an approved channel. Only the PIN code and IFSC you type are sent to public lookup services, to fill in area, city, state and bank branch.

Number of insured persons

For two or more people, additional member details will appear below.

Personal Details (Proposer / Primary)

Proposer NameDate of Birth

Age: —

Mobile No.

+91

Enter a valid 10-digit Indian mobile number.Email IDUID No.PAN No.Height (cm)Weight (kg)RelationFull Address (if different from UID) PIN CodeEnter 6-digit PIN code to fill area, city and state. Area City / District State

Nominee Information

Nominee NameAgeRelation

Bank Details

IFSC CodeEnter 11-character IFSC to fill bank and branch.Account No.Bank NameBranch

Attachments Checklist

Masked UID Copy PAN Copy Bank Passbook / Cheque Leaf Copy Photograph

Pre-Existing Disease (PED)

Do you or anyone in your family have any PED (Pre-Existing Disease)? *

YES NO

For your privacy, do not share this form publicly. Verify all personal, health and bank details before providing them to an authorized insurance representative.