Insurance Lead Generation Form
Comprehensive Life Insurance Data Collection
This form will automatically generate Excel sheet and send to operation@digi-loan.com
Basic Information
Partner/Employee Name
*
Partner Mobile No
*
Insurance Co Name
*
Select Insurance Company
Bandhan Life
Pramirica Life
Kotak Life
Central General Life
India First Life
HDFC Life
iPru
Sud Life
Tata AIA
Go Digit
Others
Name of Life Assured or Proposer
*
Date of Birth
*
Place of Birth
Mobile No
*
Email
Height
Weight
Pan Number
Aadhar Card No
*
Enter 12-digit Aadhar number
Address Information
Permanent Address as per Aadhar or Address Proof
Address Proof
Select Address Proof
Aadhar Card
Passport
Driving License
Voter ID
Utility Bill
Present Landmark
Current Communication Address (if different from Permanent)
Professional Information
Occupation
Designation
Organisation Name
Industry Type
Select Industry
IT/Software
Banking/Finance
Healthcare
Education
Manufacturing
Retail
Government
Others
Gross Total Annual Income (₹)
Life Insurance Amount Assured (₹)
Family Information
Mother's Name
Mother's Age
Father's Name
Father's Age
Marital Status
Select Status
Single
Married
Divorced
Widowed
Medical History & Habits
Consumption Habits
Drinking Habits
Select
Never
Occasionally
Regularly
Ex-Drinker
Alcohol Consumption Details
Smoking/Tobacco Habits
Select
Never
Occasionally
Regularly
Ex-Smoker
Tobacco Consumption Details
Drug Consumption
Select
Never
Past
Current
Drug Details
Any Health Issues (BP/Diabetes etc. and any other medical history)
To opt for the policy under MWPA (Yes/No)
Existing Life Insurance Policy Details
Insurer
Policy No.
Sum Assured
Premium
Maturity Date
Nominee Information
Nominee Name
Nominee Gender
Select Gender
Male
Female
Other
Nominee Date of Birth
Relationship
Select Relationship
Spouse
Son
Daughter
Father
Mother
Brother
Sister
Others
Allocation %
Family History
Family Medical History Details
Product Details
Product Name
Premium Amount (₹)
Premium Payment Mode
Select Mode
Annual
Half-Yearly
Quarterly
Monthly
Annual Premium (₹)
Premium Payment Term (Years)
Policy Term (Years)
Upon submission:
Excel sheet will be automatically generated and sent to operation@digi-loan.com
Submit Insurance Lead
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