Online Policy Proposal

Select Zone:* Select zone Karachi (Southern) Zone Karachi (Central) Zone Karachi (Eastern) Zone Quetta Zone Multan Zone Sahiwal Zone RahimYar Khan Zone Dera Ghazi Khan Zone Bahawalpur Zone Vehari Zone Faisalabad Zone Sargodha Zone Jhang Zone Lahore Central Zone Lahore Western Zone Gujranwala Zone Narowal Zone Sialkot Zone Rawalpindi Zone Gujrat Zone Islamabad Zone Mirpur (AK) Zone Jhelum Zone Gilgit Zone Peshawar Zone Abbottabad Zone Swat Zone Kohat Zone Hyderabad Zone Sukkur Zone Larkana Zone Mirpurkhas Zone Benazirabad (Nawabshah) Zone Group & Pension Rawalpindi Zone Group & Pension Peshawar Zone Group & Pension Lahore Zone Life Insurance Business (Gulf) Sheikhupura Zone Faisalabad Western Zone Gulf Zone

Your full name:*

Father’s / husband’s full name:

CNIC No:*

Date of birth:*

Residential address:

Contact No (Res):*

Contact No (Off):*

Contact No (Mobile):

Fax:

Email:*

Your occupation:

Monthly income:*

Choose Plan: (choose a Policy) Whole life Assurance Endowment Assurance Anticipated Endowment Assurance Child Protection Assurance Optional Meturity Assurance Jeevan Sathi Assurance Nigehban Plan (Annual Premium) Nigehban Plan (Single Premium) Shad Abad Assurance Sunehri Policy Child Education and Marriage Assurance (With built in family benifit) Child Education and Marriage Assurance (Without builtin family income benifit) Shehnai Policy Muhafiz Plus Assurance

Choose Term: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100

Supplementary Cover: none Accident death & indemnity benefit(AIB) Accidental death benefit (ADB) Family income benefit (FIB) Waiver of premium (WP) Special waiver of premium (SWP) Term insurance (TI) Guaranteed insurability (GI) Refund of premium rider (RPR) Hospital & surgical benefit (H&S)

If you have selected a joint life plan, please specify the name of other person with relationship to be insured?:

Cigarettes:

Pan/ Niswar:

Alcohol:

Drugs:

Do you have any physical impairment? If yes, please state its nature:

Do you now or ever had heart disease, diabetes, high blood pressure, TB, jaundice or liver, stomach, renal disease, cancer, asthma, epilepsy, nervous or psychological disorders? If so specify with dates:

Are you in good health? If not, describe the nature of ailment:*

Please specify where should our representative call you?*
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