Online Insurance
Select User
Insurance Form
In Case of Deceased Father
In Case of Deceased Mother
Do you have siblings?
Required Supplementary Contracts(Optional Benefit)
Do you (Life to be assured) have previous insurance with this company or any other life insurance company?
Health and common question
Insurance Form JU1 General Info
Permanent Address
Temporary Address
Personal Details
Occupational Detail
Please Give Detail of Life Insurance
Proposed Coverage Amount (SA)
Required Supplementary Contracts(Optional Benefit)
In case of death during insurance period, who do you want to nominate to receive benefit?
(Insured can change beneficiary at any time and if insured had not nominated any beneficiary or if nominated beneficiary is not alive at the time of death of insured, benefites as per this policy will be given to legal heir of insured as per Article 38 of Insurnace Act 2049.
Do you intend to work as below?
Do you (Life to be assured) have previous insurance with this company or any other life insurance company?
Bank Account Details
(In order to receive payment from the insurance company)
Female Proposer:
Is Child Insurance ?
Declaration

I hereby declare that all given answers of questions asked above are true and complete and I have not concealed any conditions or facts required for insurability risk assessment of life to be assured. I understand that if any such facts are proved to be concealed or not true, agreement between me and JyotiLife Insurance Company Limited shall be void from the date of commencement of this agreement and I will have no objection if company denies to pay claim on this ground.

I agree that this proposal form, declaration and attached health details documents shall be the integral part of this agreement between me/ life to be assured and JyotiLife Insurance Company. I understand that date mentioned in first insurance premium receipt along with its policy number issued to me by the JyotiLife Insurance shall be the date of commencement o this insurance. I agree to accept life insurance policy related documents issued by the insurer.

I authorise JyotiLife Insurance Company Limited to obtain information from any medical doctor or any medical facilities of any time from where I / life to be assured is getting medical checkups and also to inquire and collect necessary information at any time from other insurer where I / life to the assured had applied for insurance. I give all rights to such concern person or organization to provide information required for the purpose of insurance and I shall no file a complain on ground of laws or rules and regulations against publishing such information.

Witness incase Proposer is Illeterate:
Health Declaration Form JU2 Details of Life to be assured
Proposed Insured's
Family History (Alive)
Mother:
Father:
Brother:
Sister:
Spouse:
Children:
Family History (Dead) Mother:
Father:
Brother:
Sister:
Spouse:
Children:
General Details
Please answer below questions in "Yes" or "No"
Did you ever had or have been diagnosed for treatment of or surgery for following disease? Please answer below questions in "Yes" or "No".
Details of proposer if assured and proposer is not same
Declaration

I hereby declare that all given answers of questions asked above are true and complete and I have not concealed any conditions or facts required for insurability risk assesment of like to be assured. I understand that if any such facts are proved to be concealed or not true, agreement between me and JyotiLife Insurance Comapny Limited shall be void from the date of commencement of this agreement and I will have no objection if company denies to pay claim on this ground.

I agree that this proposal form, declaration and attached health details documents shall be the integral part of this ag=reement between me/ life to be assured and JyotiLife Insurance Comapny. I understand that date mentioned in first insurance premium receipt along with its policy number issued to me by the JyotiLife Insurance shall be the date of commencement o this insurance. I agree to accept life insurance policy related documents issued by the insurer.

I authorise JyotiLife Insurance Company Limited to obtain information from any medical doctor or any medical facilities of any time from where I / life to be assured is getting medical checkups and also to inquire and collect necessary information at any time from other insurer where I / life to the assured had applied for insurance. I give all rights to such concern person or organization to provide information required for the purpose of insurance and I shall no file a complain on ground of lawsor rules and regulations against publishing such information.

Witness incase Proposer is Illeterate:
Agent Report Form JU3 General Info
Proposer Info



Other Info
KYC Form JU5
Address & Contacts
General Info
Income
Amount
Agent Info
MORAL HAZARD REPORT (Form No: JU6)