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DATA SHEET FOR Policy Holder / Proposer

Application Number
TRACK ID: RMPJITENDRADPR Product Name
PREMIUM AMOUNT: Rs. 7990 SUM ASSURED : Rs. 240000
Personal Details
Name - Life Assured MR / MRS / MISS JITENDRA KUMAR AHARI

Date Of Birth: 13-03-1969 Gender MALE Marital Status:MARRIED Nationality INDIAN

Education: 1/9/1900 Occupation FARMER Annual Income 80000


In Case of Service (mention
Nature of Duties AGRICULTURE name & address of the
employer)
Do You Have Existing Policy with FGI Yes No If Yes Qoute Policy No.

Father's NameLAL JI AHARI


Complete Name before marriage ( In case of female)
Is your Occupation associated with any specific hazards Yes No
Communication Details

Residence Address:77 , VIKASOTA , KALU GAMADA , BHOJATO KA ODA ,

LandMark

DUNGARPUR
City/Town: Taluka: KALU GAMADA Dist: DUNGARPUR

State: RAJASTHAN Pin: 314037 E-mail id:

Telephone : Mobile:9602378917

NOMINEE DETAILS

Name: LAXMI AHARI Date Of Birth:21-08-1972

Relationship to Insured Person: WIFE

Incase if nominee is a minor - Please provide following appointee details.


APPOINTEE DETAILS

Name Date Of Birth:

Relationship to the Nominee:

Address :

PROOFS DETAILS

Age proof: Address proof: ID proof:

All Proofs should be Clearly SELF ATTESTED BY PROPOSER (CUSTOMER)

Females Only

Are you pregnant.


yes / No If yes - Duration in Weeks Husband Occupation & Annual Income:

SIGNATURE

Leader Name: HARI K TRIVEDI Place: UDAIPUR


Mobile No. 9269696191
Note :- * Demand Draft on the Name of “ FUTURE GENERALI INDIA LIFE INSURANCE CO LTD” payable at CHENNAI * Incase Insured
is minor, Fill up the 2 data sheet forms - One for child & Another for Proposer - both Data Sheets should be Signed BY Proposer.
Note :- * Demand Draft on the Name of “ FUTURE GENERALI INDIA LIFE INSURANCE CO LTD” payable at CHENNAI * Incase Insured
is minor, Fill up the 2 data sheet forms - One for child & Another for Proposer - both Data Sheets should be Signed BY Proposer.

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