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For Insurance Policy Login Data Sheet
Dr Milind Sampgaonkar
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* Indicates required question
Full Name
*
Your answer
Father Full name
*
Your answer
Mother Name
*
Your answer
AADHAR Number
*
Your answer
AADHAR Link Mobile Number
*
Your answer
Address if Different from AADHAR
Your answer
Email ID
*
Your answer
Place Of Birth
*
Your answer
Marital Status
*
Married
single
Other:
Education Qualification
*
Your answer
Spouse Name
Your answer
Occupation
*
Service
Business
Other:
Annual Income
*
Your answer
Name of Present Employer
Your answer
Number of years (In Service )
Your answer
Previous Policy If any (Please quote Policy Number)
Your answer
Family History
Live
Death
Father
Mother
Sister
Brother
Spouse
Kids
Live
Death
Father
Mother
Sister
Brother
Spouse
Kids
Clear selection
State of Health
*
Your answer
Height
*
Your answer
Weight
*
Your answer
Nominee Name & Age
*
Your answer
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