Your Life is precious Sakshi Consultacy (MDRT) JEEVAN BIMA

for your family Ramesh R. Wable DATA SHEET

Insurance Advisor, MDRT (USA)

Full Name ……………………………………………. Short Name ………………… Agency Code ………...

Plan & Term …………………… Sum Assured ……………….. Mode …………… Premium ………………
Address Present ....................................................................................................................................................
…………………………………………………………………………………………………………………..
Mobile (1) ……………………….. Mobile (II) ………………………. Email ………………………………..
Occupation ………………………….. Nature of Job …………………… Length of Service ………………...
Name of Employer ……………………………………………………………………………………………...
D.O.B ………………… Age ……….. Age Proof ………………… Place of Birth …………………………..
Qualification …………………………………….. Income Rs …………………………………………………
Father’s Name ………………………………………… Mother’s Name ……………………………………
Nominee’s Name …………………………………………….. Age ………….. Relation ……………………..
Appointee’s Name …………………………………………….. Age …………. Relation …………………….
Height ………………………… Weight ……………………….. Mark of identification ……………………..
If expired
Cause of
Family History Age Health age of
Death
Death
Father
Mother
Brother alive No.
PHOTOGRAPH
Dead No.
Sister alive No.
Dead No.
Husband / Wife
Children alive No.
Dead No.
DETAIL OF PREVIOUS INSURANCE
Br. Unit Policy No. Sum Assd. Prem. T.T Mode D.O. Commencement

IN CASE OF LADIES
Husband’s Name …………………………………… Occupation …………………….. Income ……………..
DETAIL OF Husband’s Policies :
Enclosed :
Unit Policy No. Sum Assd. Prem. D.O. Commencement Age Proof
Photograph
Address Proof
Pan Card
Age of birth of Younger Child Signature ……………………………
You Pregnant now :
two reference
Name ……………………………………. Mob ……………………………. Place : …………………………
Name ……………………………………. Mob ……………………………. Place : …………………………