Client Registration Form

Client Registration Form

Congratulations on taking a life changing decision for yourself and for your loved ones.
Tell Us About You

All information is kept in strict confidence.
Name (As per Bank Account/PAN)*

First NameMiddle NameLast Name
Mobile Number*
E-mail*
example@example.com
Aadhar Number *
Address, if different in Aadhar card.
PAN No*
Any Previous history of Disease*
Birth Date*

MonthDayYear
Occupation:

BusinessServicesSelf EmployedOther
Name of Employer and length of Service.
Income from Employment Or Professions

Between 1 Lacs to 2.5 LacsBetween 2.5 Lacs to 5 LacsBetween 5 Lacs to 10 LacsBetween 10 Lacs to 15 LacsMore than 15 Lacs
Height*
In Cms
Weight*
In KGs
Chest*
In Cms
Smoker?

YesNo
Are you tested positive for Covid-19 and under isolation presently?

YesNo
If vaccinated, Date of vaccination

MonthDayYear
Date
Mark of Identification
Anything that physically gives your identity.

Family History*

Previous Insurance Details (If Any)

Bank Account Details
Account Number*
Bank Name & Address*
Name of Account Holder*
IFSC code*
MICR CODE*
Upload Documents here

Please upload the clear image of the PAN. Aadhar Card and a cancelled Bank Cheque leaf.
Cancelof
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake the responsibility to inform you of any changes therein, immediately.
Should be Empty:

Bank Account Details