Name of the Insured AA BB CC

Date of Birth 7/12/1958 5/17/1960 10/31/1983

Height 5'6" 5'1" 5'6"
Weight 60 74 58
Work Profile JOB House wife Job
Present City
Native City
1. Sterlisation Minor stiches on
Minor stiches under chin
Any surgery done ever? temple due to
due to road accident 2. Garbhashay road accident
Yes. Due to road Yes. For above 2
Have You ever been hospitalized? NO
accident. reason.
Any disease related to heart or any Father in law died Father died to
other critical ailment in near family, to cancer caused by cancer caused by
may be In Laws... ? smoking smoking
Any hereditary problem in either Not such Not such Not such
family?

Any particular addiction or problem 1. Drinking -1 peg daily No No

in anyone's lifestyle?
2. Tobacco - Never
Any form of exercise on regular Morning walk Morning walk Morning walk/Yog
basis?

Has there been any ailment, for

which anyone took medication and
then stopped after recovery?

What are existing ongoing Blood presssure Goiter on one side No

medicines, if any ?
Share information relevant to Normal fit Normal fit Unmarried
physical fitness of spouse.
How much Minimum Sum insured Best suitable Best suitable Best suitable
required?
What's maximum premium, You can 18000
pay Comfortably ?

What is your job or business profile Business Homemaker business

Do you travel a lot , Within City or No No No

Inter State ?
Maternity delivery was Normal or C - Normal -
Section? ( If Applicable)
Do you take part in adventure No No No
sports?
Do you travel abroad Often ? No No No

When do you want to buy Policy ? In ten days

Pl Share details of Any existing no

Health Insursance Policy , If Any
Have you ever closed any Health no
Insurance Policy ever ?
 DD
9/29/1989
5'9"
64
Job

No

Not such

No

Morning walk/Yog

Vascular
headache, low bp

No

Unmarried

Best suitable

business

little bit

No

No