Advisor Confidentiality Report Template (Online Cases) printable pdf download

Advisor Confidentiality Report (Online Cases)

Customer Name:______________________________________

Application no:_________________________

1. Nature of Proposal:

Medical

Non-medical

2. Purpose of Insurance: _______________________________________________________________________________

3. Nature of Work: ____________________________________________________________________________________

4. How do you know the Life Assured/ Proposer: ________________________________________________________

5. How long have you known the Life Assured/ Proposer:

Years

Months

6. Is the Life Assured/ Proposer related to you?

Yes

If yes, give details: ___________________________________________________________________________________

7. Income details of Proposer:

Salary

Business

Agricultural

Others

Total

Rs. per annum

Income Proof verified:

ITR

Form 16

Pay-Slip

Balance sheet

P&L

Others

Please specify

8. Personal Assets:

House:

Owned

Rented

Co Provided

Vehicle:

4 wheeler

2 wheeler

None

9. General health details of Life to be assured as Observed/ Informed to you:

Physical handicap/ Deformity: Yes

Mental Retardation:

Yes

History of Illness/ Surgery:

Yes

Medical Investigation: Yes

10. Any other risk associated with Occupation, Sports Pursuit, Financial/ Social Position or Personal Habits of

Life to be Assured/ Annuitant that could affect the risk in the Insurance Proposal, please provide details:

____________________________________________________________________________________________________

11. Other Remarks: _____________________________________________________________________________________

____________________________________________________________________________________________________

I hereby declare that foregoing statements are true to the best of my knowledge and belief. I state that the

proposal has been filled up proposer/ person authorized by the proposer after fully understanding the nature

of the questions in the proposal form and importance of disclosing all material information that has been

explained by me to the proposer. I recommend this proposal for insurance. I confirm having verified the

identity and address of the customers and proofs submitted for the same.

Date:

____________________________________

Place: ____________________________________

(Signature of specified person)

FOR ICICI PRUDENTIAL LIFE’S OFFICE USE ONLY

LOB/ Agent’s Code: ______________________

Bank/ Branch/ Source: ____ / _____ / _____

Opportunity ID: __________________________

FSC Code: ______________________________

Application no: __________________________

LIM/ CSR Code: _________________________

Bank Acc No: ____________________________ CAFOS Code: ___________________________

Advisor Confidentiality Report Template (Online Cases)

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