Balio - Term Insurance
Basic Details form
Section-1: Basic Details
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Correspondence Address (as per Aadhar Card)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Place of Birth
Date of Birth
-
Day
-
Month
Year
Date
Gender
Male
Female
Transgender
Nationality
Indian
Other
Marital Status
Married
Unmarried
Widow(er)
Divorced
Resident Status
Resident Indian
NRI
PIO
Foreign National
Education
Post Graduate
Graduate
Diploma
12 pass & below
Occupation
Salaried
Professional
Self Employed
Student
Housewife
Retired
Other
Name of the Org./Business
Annual Income
Smoking Or Chewing Tobacco
Yes
No
Drinking Habbit
Regular
Ocassionally
No
Section-2: Additional Details
Mother's Name
First Name
Last Name
Father's Name
First Name
Last Name
Spouse Name
First Name
Last Name
Height (in cm)
Weight (in Kg)
Nominee Details
*
Appointee Details if Nominee is Minor
COVID Vaccination Details
Bank Account Details
Do you have any existing Term Insurance, Life Insurance, ULIP's Policy going on?
Yes
No
Details of existing Term Insurance, Life Insurance, ULIP's Policy
Have any proposals on your life / application for reinstatement ever been postponed or declined.
Yes
No
Are you a politically exposed person?
Yes
No
Lifestyle Details:
Rows
Yes
No
If Yes, Details Please
Is your occupation associated with any specific hazard, or do you take part in activities or have hobbies that could be dangerous in any way?
Are you employed in the armed, paramilitary, or police forces?
Family details of the life to be assured (include parents/siblings): Are any of your family members suffering from/have suffered from/have died of heart disease, Diabetes Mellitus, cancer, or any other hereditary/familial disorder, before 55 years of age? If yes, please provide details below.
Have you lost weight of 10 kgs or more in the last six months?
Have you undergone or been advised to undergo any tests/investigations or any surgery or hospitalized for observation or treatment in the past?
Did you have any ailment/injury/accident requiring treatment/medication for more than a week, or have you availed leave for more than 5 days on medical grounds?
Do you have any congenital defect/abnormality/physical deformity/handicap?
Have you ever suffered or been diagnosed with or been treated for any of the following?
Rows
Yes
No
If Yes, Details Please
Hypertension/High BP/High cholesterol
Undergone angioplasty, bypass surgery, heart surgery
Asthma, Tuberculosis, or any other respiratory disorder
Any Gastrointestinal disorders like Pancreatitis, colitis, etc.
Genitourinary disorders related to kidney, prostate, urinary system
HIV infection/AIDS or positive test for HIV
Psychiatric or mental disorders
Chest pain/Heart attack/any other heart disease or problem
Diabetes/High blood sugar/sugar in urine
Nervous disorders/stroke/paralysis/epilepsy
Liver disorders/Jaundice/Hepatitis B or C
Cancer, Tumour, Growth, or cyst of any kind
Any blood disorders like anemia, Thalassemia, etc.
Any other disorder not mentioned above
Section-3: Upload Documents
Recent Photo - Full Body
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Pan Card
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Aadhar Card (Front & Back Both)
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Cancelled Cheque
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Bank Statement (Last 6 months - With Salary Credit)
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Income Documents - 3 Latest Salary Slip (For Salaried) or 3 year ITR (For Self Employed)
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Save
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