LIFE INSURANCE CORPORATION OF INDIA
Special Questionnaire to be completed in respect of NRIs
Divisional Office
Branch Code
Proposal No.
A. To be filled in by the Dean / Principal in respect of students and by the Employer in respect of employed persons
| Sr. No. | Particulars | Answer | |
|---|---|---|---|
| 1. | Name of the proposer | ||
| 2. | When did he / she join your college / university / firm? | ||
| 3. | Date of birth and age | ||
| 4. | Educational qualification | ||
| 5. | General appearance | ||
| 6. | Any identification mark/s? | ||
| 7. | Does he / she have any physical deformity? (impaired sight or hearing, physical impairment or mental retardation) | ||
| 8. | His / her professional status (type of duties performed) | ||
| 9. | Has he / she remained absent from college / duties on medical grounds? If so, period of absence and reasons thereof | ||
| 10. | What are his / her habits / hobbies? Does he / she consume tobacco, snuff or other narcotic substances in any form, or alcoholic drinks? | ||
| 11. | His / her monthly salary / stipend / teaching allowance | ||
| 12. | Results of any routine medical check-up | ||
Place
Date
Signature & seal of Dean / Principal / Employer
B. To be filled in by the Personal Physician in respect of self-employed persons
| Sr. No. | Particulars | Answer | |
|---|---|---|---|
| 1. | Name of the proposer | ||
| 2. | Since how long do you know the proposer? | ||
| 3. | Age of the proposer | ||
| 4. | General appearance | ||
| 5. | Any identification mark/s? | ||
| 6. | Does he / she have any physical deformity? (impaired sight or hearing, physical impairment or mental retardation) | ||
| 7. | Has he / she taken any treatment from you? Yes / No. If yes, full details and the period of treatment | ||
| 8. | What are his / her habits / hobbies? Does he / she consume tobacco, snuff or other narcotic substances in any form, or alcoholic drinks? | ||
| 9. | Any information about his / her financial status? | ||
Place
Date
Signature & seal of Personal Physician