Full Name*

Age*

Age Proof Document*
SelectCitizenshipDriving LicenseBirth CertificateSchool CertificateSLC Mark-SheetPassportPan Card

Education*
SelectNo Formal EducationPrimary SchoolSecondary SchoolHigher Secondary/IntermidiateBachelor DegreeMaster DegreePHD

Nature of Work*
SelectOfficer/ManagerAccountantPrincipalTeacherBusinessmanInsurance AgentVehicle DriverMilitary/PoliceGuardSub-InspectorPainterCarpet WorkerElectric WorkerDiversConstructionMine Worker/SupervisorOthers

Mobile Number*

Blood Group
SelectA+B+AB+O+A-B-AB-O-

Father's Name*

Husband/Wife's Name*

Last Child's Name*

Permanent Address

Zone*
SelectMechi-EDRKoshi-EDRSagarmatha-EDRJanakpur-CDRNarayani-CDRBagmati-CDRGandaki-WDRLumbini-WDRDhaulagiri-WDRKarnali-MWDRRapti-MWDRBheri-MWDRSeti-FWDRMahakali-FWDR

Municipality/VDC*

Tole*

Corresponding Address

Zone*
SelectMechi-EDRKoshi-EDRSagarmatha-EDRJanakpur-CDRNarayani-CDRBagmati-CDRGandaki-WDRLumbini-WDRDhaulagiri-WDRKarnali-MWDRRapti-MWDRBheri-MWDRSeti-FWDRMahakali-FWDR

M/VDC*

Tole*

For Life Insurance

Sum Assured Amount(Rs)*

Meturity Term(Years)*

Premium Paying Term

Date of Birth*

Gender*
SelectMaleFemale

Citizen/ID NO*

Occupation*

Working Office*

Office Contact No

Your Email*

Mother's Name*

H/W Father's Name

Child DOB*

District*

Ward No*

Block No

District*

Ward No*

Block No

Insurance Type*
SelectEndowment PolicyWhole Life PolicyMoney Back PolicyChild PolicyJoint Life PolicyShort Term PolicyTripal Benefit PolicySingle Premium Policy

Payment Mode*
SelectYearlyHalf YearlySingleMonthlyQuarterlySalary Saving

Monthly Income(Rs)*