DATA SHEET

Branch Policy No. Risk Date

Name SA T/T Mode

Address

Permanent Address
Phone No. 1-
Phone No. 2-
Father’s Name Deposit Rs.
Nominee By 1. Chq No. 2. Cash
Relation Age Bank/Br.
Present Occupation & Nature of Duties A/c: SB/CD/CC/OD
Date of Birth Age
Name of Employer Age Proof
Length of Service Place of Birth
Husband’s Name Education
Occupation/PAN: PAN
Height: Weight: Chest Abd
Missing Teeth Deformity Operation
Disease Spec’s Power Identity Mark
For Female Last Dt. Of Menstruation Dt. Of Last Delivery
.P. No. S.A. T/T Mode Premium Year Status Branch

Family Alive Death

History Nos. Age Nos. Year Age Duration Cause
Father
Mother
Brother
Sister
W/H
Children S D

Signature Life Assured Signature