Sheet1

L & T Insurance
Proposer, Nominee and Insured person Details
Plan Type
Proposer's father's name
Proposer Name
Proposer DOB
Proposer 's Address
City
State
Pin code
Proposer Gender
Contact Number
PAN No. (Not Mendantory)
Alternative contact Number
Email ID
Proposer's occupation
Annual Income Of Proposer in Lacs
If paid for 2 years
Name of Insured Person -1
Relationship of Insured -1 with proposer
DOB of Insured -1
Gender of Insured -1
Occupation of Insured -1
Pre-existing Disease
Height of Insured -1
Weight of Insured -1
Sum Insured
Nominee Name
Relationship of Nominee with Insured -1
Name of Insured Person -2
Relationship of Insured -2 with proposer
DOB of Insured -2
Gender of Insured -2
Occupation of Insured -2
Pre-existing Disease
Height of Insured -2
Weight of Insured -2
Sum Insured
Nominee Name
Relationship of Nominee with Insured -2
Name of Insured Person -3
Relationship of Insured -3 with proposer
DOB of Insured -3
Gender of Insured -3
Occupation of Insured -3

Answer Format
Individual/ Floater
(Text)
(Text)
(DD/MM/YYYY)
(Text)
(Text)
(Text)
(Text)
Male/ Female
(Text)
(Text)
(Text)
(Text)
Salaried/ Self employed/ Retired
(Text)
Yes/ NO
(Text)
(Text)
(DD/MM/YYYY)
Male/ Female
Salaried/ Self employed/ Retired
Yes/ NO
(In Centimeters)
(In Kilograms)
(In Lacs)
(Text)
(Text)
(Text)
(Text)
(DD/MM/YYYY)
Male/ Female
Salaried/ Self employed/ Retired
Yes/ NO
(In Centimeters)
(In Kilograms)
(In Lacs)
(Text)
(Text)
(Text)
(Text)
(DD/MM/YYYY)
Male/ Female
Salaried/ Self employed/ Retired

Page 1

Sheet1
Pre-existing Disease
Height of Insured -3
Weight of Insured -3
Sum Insured
Nominee Name
Relationship of Nominee with Insured -3
Name of Insured Person -4
Relationship of Insured -4 with proposer
DOB of Insured -4
Gender of Insured -4
Occupation of Insured -4
Pre-existing Disease
Height of Insured -4
Weight of Insured -4
Sum Insured
Nominee Name
Relationship of Nominee with Insured -4
Name of Insured Person -5
Relationship of Insured -5 with proposer
DOB of Insured -5
Gender of Insured -5
Occupation of Insured -5
Pre-existing Disease
Height of Insured -5
Weight of Insured -5
Sum Insured
Nominee Name
Relationship of Nominee with Insured -5
Name of Insured Person -6
Relationship of Insured -6 with proposer
DOB of Insured -6
Gender of Insured -6
Occupation of Insured -6
Pre-existing Disease
Height of Insured -6
Weight of Insured -6
Sum Insured
Nominee Name
Relationship of Nominee with Insured -6

Yes/ NO
(In Centimeters)
(In Kilograms)
(In Lacs)
(Text)
(Text)
(Text)
(Text)
(DD/MM/YYYY)
Male/ Female
Salaried/ Self employed/ Retired
Yes/ NO
(In Centimeters)
(In Kilograms)
(In Lacs)
(Text)
(Text)
(Text)
(Text)
(DD/MM/YYYY)
Male/ Female
Salaried/ Self employed/ Retired
Yes/ NO
(In Centimeters)
(In Kilograms)
(In Lacs)
(Text)
(Text)
(Text)
(Text)
(DD/MM/YYYY)
Male/ Female
Salaried/ Self employed/ Retired
Yes/ NO
(In Centimeters)
(In Kilograms)
(In Lacs)
(Text)
(Text)

Medical Questionnaire
Does any person,proposed insured suffer from/have been
treated for any heart related ailment/blood pressure
Does any person,proposed insured suffer from
Diabetes/Asthma/Epilepsy

Page 2

(YES/ NO)
(YES/ NO)

Sheet1
Does any person,proposed insured suffer any other
disease/ailment

(YES/ NO)

Is any person,proposed to be insured receiving any

treatment/medication or have in the past received
treatment or undergone surgeries for any medical
condition/disability?
Please provide details of hereditary medical history: if any
Name of the person proposed to be insured
Name of illness/injury suffering from or suffered in the past
Treatment/medication received/receiving
Date first diagnosed/treated
For top-up plan
Base policy name(company name)
Deductible amount of policy(base policy's sum insured)

Page 3

(YES/ NO)
(YES/ NO)
(Text)
(Text)
(Text)

(Text)
(Text)

Sheet1

L & T Insurance
Your Answer

Page 4

Sheet1

Medical Questionnaire

Page 5

Sheet1

Page 6