Agent Code:-

Customer Profile Sheet

Agent Name:-

BRANCH CODE :- BRANCH NAME:-

Employee Code:- Employee Name:-
SP Code:- SP Name:-
Customer Details
Life Assured Details
First Name ( Mr/ Mrs/ Miss) Gender
Middle Name DOB (DD/MM/YYYY)
Last Name Nationality
Marital Status Preferred Language for
** (If Married , Spouse Name Communication
and Age is Mandate)
Father's Name
PAN No Aadhar No
Are you a Politically Exposed Person (PEP)? YES NO
Are you a foreign national /NRI/resident of any other country other than india(for Income tax purpose)? YES NO
Proposer Details ( If Both are Same put tick mark )
First Name ( Mr/ Mrs/ Miss) Gender
Middle Name DOB (DD/MM/YYYY)
Last Name Nationality
Annual Income (INR) Occupation
PAN No Aadhar No
Are you a Politically Exposed Person (PEP)? YES NO
** If Yes, Additional Documents need to provide
PLAN DETAILS
Plan Name Premium Amount
Policy Term (PT) Premium Paying Term (PPT)
Premium Mode Sum Assured (SA)
Objective of Insurance Name of Age Proof
Payment Mode  Cash Cheque/ DD Online Specifiy
Maturity Benefit  Lumpsum Payout ( monthly / yearly)
Death Benefit  Lumpsum Payout ( monthly / yearly)
** Benefit Payout option is mandate for Assured Income Plan (AIP)
RIDERS DETAILS ( IF OPTED)
Riders Name Term Sum Assured
Shriram Accident Benefit Rider
Shriram Critical Illness Cover Rider
Shriram Extra Insurance Cover Rider
Shriram Family Income Benefit Rider
Height ( in cms / feet) Weight (KGs)
B - COVID 19

Have you ever been quarantined due to a possible exposure to novel coronavirus or have you been in close contact with
YES NO
anyone who has been quarantined or who has been diagnosed with novel coronavirus (SARS-CoV-2/COVID-19)?

If Yes describe brief

Have you been advised to be tested or have you ever tested positive for the novel corona virus (SARS-CoV-2/COVID-19)?
Or, are you awaiting the result of a test which has already been submitted for the novel coronavirus (SARS -CoV-2/COVID- YES NO
19)?
Have you experienced any of the following symptoms within the last 14 days? (  )
• Any fever • Shortness of breath • Rhinorrhea (mucus • Gastro-intestinal symptoms such as nausea,
• Cough • Malaise (flu-like tiredness) discharge from the nose) vomiting and/or diarrhea
• Sore throat
If yes, to any of these, please indicate which and provide full information.

Do you have a history of travel outside India in last 15 days or do you intend travel outside India in next 3 months. If yes, please provide complete details of travel include place
and dates
If Yes describe brief YES NO
 MEDICAL DETAILS
Are you at present in good health YES NO
Do you smoke/chew/ inhale any tobacoo YES NO
Do you consume alcohol YES NO
Are you physically handicapped or any deformity YES NO
Where you ever disgonesed with ailments related to heart, kidney, diabetes, cancer, liver, HIV or any other abnormility
YES NO

Are You Currently Pregnant? YES NO No of Weeks -

Have you ever had any miscarriages/abortions in past? YES NO
Last delivery date YES NO / /
ADDITIONAL DETAILS
LA Communication Address LA Permanent Address ( if both address is same put tick mark )
Address line 1 Address line 1
Address line 2 Address line 2
Area Area
City City
Distt Distt
State State
PIN PIN
LA Mobie Number Do you wish to be contacted on WhatsApp? YES NO
Education Qualification Email ID
OCCUPATION DETAILS
Occupation Occupation Sub Category
Nature of Duties Length of Service
Source of Income Annual Income
Has any proposal/ application for revival for life, medical, health or critical illness cover been postponed, declined or
accepted on special terms? YES NO

If Yes describe reason

PREVIOUS INSURANCE DETAILS
Company Name Policy no
Insurance Cover Policy Status
FAMILY HISTORY
Name Age Health Status
Father
Mother
Spouse
Son
Daughter
Brother
Sister
** Year of Death and Cause of Death is Mandatory , if any Family Member is experied

NOMINEE DETAILS
First Name ( Mr/ Mrs/ Miss) Last Name
Gender DOB / Age
Note :- If nominee is minor Appointee details Required Relationship with LA

Appointee Relationship with

Appointee Name
LA
BANK DETAILS
Bank Name Branch Name:-

A/C no IFSC Code

Customer's Signature Partner Employee's

Signature

Date Partner Employee's Name