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Aadhaar no of IP is not validate through ekyc, Kindly do the needful
Proposal Form CSC BACHAT PLUS
Agent Details
VLE/RAP code
*
VLE/RAP name
VLE/RAP State
VLE/RAP district
IC Code
STM code
STM Name
Employee Code
VLE Mobile Number
Sector
*
--Select--
Urban
Rural
Urban-Social
Rural-Social
Proposal Type
Personal Details
Aadhar Card
*
Validate Thru
--Select--
Finger Print
Iris
OTP
Title
*
--Select--
Mr
Mrs
Miss
Master
Name
DOB (DD/MM/YYYY)
Entry Age
Gender
Nationality
Place of Birth
PH Details
Aadhar Card
*
Validate Thru
--Select--
Finger Print
Iris
OTP
Title
*
--Select--
Mr
Mrs
Miss
Master
Name
DOB (DD/MM/YYYY)
Entry Age
Gender
Nationality
Place of Birth
PH Address Details
C/O
Landmark
Locality
VTC
District
House No.
State
Country
PINCODE
E-mail id
Mobile No.
Family Details
Relation of Proposer to Proposed Insured
*
--Select--
Self
Father
Mother
Grandfather
Grandmother
Legal Guardian
Marital Status
*
--Select--
Single
Married
UnMarried
Widowed
Divorced
If Married, Spouse Date of birth (DD/MM/YYYY)
Place of Birth
*
Father's Name/Husband's Name
*
Nominee Details
Name & Surname
*
Relationship to Nominee
*
--Select--
Sister
Father
Mother
Father in Law
Mother in Law
Son
Daughter
Brother
Niece
Nephew
Husband
Wife
Grandfather
Grandmother
Grandson
Granddaughter
Others
Not Mentioned
Date of Birth (DD/MM/YYYY)
*
Place of Birth
*
Name of Appointee
Relationship to Nominee
--Select--
Father
Mother
Grandfather
Grandmother
Guardian
Aunty
Uncle
Brother
Sister
Nephew
Niece
Others
Not Mentioned
Date of Birth (DD/MM/YYYY)
Place of Birth
Coverage Information
Policy Term
*
--Select--
10
15
Premium Term
*
Premium Amount
*
Premium Frequency
*
--Select--
Annual
Half-Yearly
Quarterly
Sum Assured
*
Total Amount Payable
Bank Details
IFSC code
Bank Name
Bank Branch Name
Account Number
Renewal Pay Mode
*
--Select--
Cash
Cheque
Draft
Declarations of Good Health of LA
Yes
No
Are you presently in Good Health?
*
Height(cms)
*
Weight(kgs)
*
Occupation
*
--Select--
Salaried
Business
Professional
Retired
Agriculture
Student
Housewife
Unemployed
Not Applicable
Not Mentioned
Yes
No
Yes
No
Are you currently pregnant??
Date of birth of your youngest child if any ? (DD/MM/YYYY)
Declaration
“I hereby declare that I have been explained by the Rural Authorised Person, all the requisite information about the nature of information required in the proposal form by the insurer and also the importance of disclosure of material information in purchase of insurance policy along with consequences of non-disclosure and inaccuracies. I further declare that the information as contained in the proposal form has been filled by Rural Authorised Person on my instructions, which are true, complete, correct and full without any concealment or misstatement and I have affixed my Thumb (Biometric) impression on being fully satisfied with the same. I understand that Bajaj Allianz Life Insurance Company Limited (Company) shall rely and act on them without verification believing them to be true, complete and correct. I undertake to bring to the notice of the Company any discrepancy in proposal form within free look period.”
I Agree
Proposal Sign Date (DD/MM/YYYY)