Policy No

0006352762
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General Details

Please confirm if the below details are correct

Insured
Full Name-
Gender-
Date of Birth-
Mobile Number-
Alternate Mobile Number
Email ID-
Annual Income (INR)-
Smoker-
Marital Status-
Education-
Occupation-
Proposer
Full Name-
Gender-
Date of Birth-
Mobile Number-
Alternate Mobile Number-
Email ID-
Annual Income (INR)-
Smoker-
Marital Status-
Education-
Occupation-
EDIT DETAILS
Personal Details

Please select the person for whom you would like to enter the Personal Details

Your Communication Details

Nationality

Indian
NRI
FNI/PIO
Others

Current address

Is the Permanent address and communication address same?

Yes
No

Permanent address

Which of the above address is your correspondence address?

Permanent
Current

Your Education Details

Post Graduate
Graduate
12th
10th
Below 10th
Student
Professional
Other

Are all your vaccinations done for life insured ?

Yes
No

Your Employment details

Salaried
Self Employed (Business)
Self Employed (Professional)
Agriculture
Housewife
Labourer/Worker
Student
Retired

Work Experience (in years)

–+

Work Experience (in months)

–+

Do you wish to avail GST Benefits ?

Yes
No

Is your source of income from none of the employment type selected above?*

Yes
No

Your Other Details

Are you politically exposed person ?

Yes
No

Are there any Conviction/Criminal proceedings against you ?

Yes
No

Age Proof Submitted*

Passport
Driving Licence
PAN Card
Aadhaar Card

Identity Proof*

Passport
Driving Licence
Aadhaar Card
Voter ID
NPR (National Population Register) Letter
NREGA (National Rural Employment Guarantee Act) Job Card

Address Proof*

Passport
Driving Licence
Aadhaar Card
Voter ID
NPR (National Population Register) Letter
NREGA (National Rural Employment Guarantee Act) Job Card

Income Proof*

Last 3 months Salary Slip
Last 3 months Bank statement with salary credit
Last 3 years ITR with Computation of Income
Last 3 years audited P/L A/C and Balance sheet

General Details

Run CKYC By running CKYC, the appropriate fields will be auto populated and data will be shared with WebOps for issuance process.

10 digit number in front of PAN card

Your Communication Details

Nationality

Indian
NRI
FNI/PIO
Others

Current address

Is the Permanent address and communication address same?

Yes
No

Permanent address

Which of the above address is your correspondence address?

Permanent
Current

Your Education Details

Post Graduate
Graduate
12th
10th
Below 10th
Student
Professional
Other

Are all your vaccinations done for life insured ?

Yes
No

Your Employment details

Salaried
Self Employed (Business)
Self Employed (Professional)
Agriculture
Housewife
Labourer/Worker
Student
Retired

Work Experience (in years)

–+

Work Experience (in months)

–+

Do you wish to avail GST Benefits ?

Yes
No

Is your source of income from none of the employment type selected above?*

Yes
No

Your Other Details

Are you politically exposed person ?

Yes
No

Are there any Conviction/Criminal proceedings against you ?

Yes
No

Age Proof Submitted*

Passport
Driving Licence
PAN Card
Aadhar Card

Identity Proof*

Passport
Driving Licence
Aadhaar Card
Voter ID
NPR (National Population Register) Letter
NREGA (National Rural Employment Guarantee Act) Job Card

Address Proof*

Passport
Driving Licence
Aadhaar Card
Voter ID
NPR (National Population Register) Letter
NREGA (National Rural Employment Guarantee Act) Job Card

Income Proof*

Last 3 months Salary Slip
Last 3 months Bank statement with salary credit
Last 3 years ITR with Computation of Income
Last 3 years audited P/L A/C and Balance sheet
Health Details

Please select the person for whom you would like to enter the Health Details

Physical Details

–+

(Feet)

–+

(Inches)

Kgs

Has there been any variation in weight during the past 6 months ? *

Lifestyle Details

Do you plan to live or travel outside India for more than 30 days?*

Yes
No

Have you in the past 5 years flown as a pilot, co-pilot, pilot instructor, student pilot or do you intend to fly?*

Yes
No

Do you take part or used to take part in any of the following adventurous hobbies/activities:

Sky Diving or Parachuting
Paragliding or Hand gliding
Mountaineering or outdoor rock climbing
Any form of racing
Any other hazardous Activity/hobby
None of the above

PARAGLIDING: Do you participate in the sport of paragliding? If YES, please provide replies to the following:

Yes
No

Yes
No

Specify the number of paragliding flights taken in the last twelve months

Do you expect to participate in any form of competition flying or record attempts or to carry out any prototype testing? If YES, please provide details.

Yes
No

Have you been involved in any accident causing injury to yourself or significant damage to your aircraft? If YES, please provide full details.

Yes
No

PARACHUTING / SKYDIVING: Do you participate in the sport of Parachuting / Skydiving? If YES, please provide replies to the following

Yes
No

For how many years you have been participating in the sport of Parachuting/Skydiving

What licence do you hold? Please provide details

How many jumps you have made till date?

How many jumps do you intend to make in the next twelve months?

Do you expect to participate in any Parachuting/Skydiving competitions or record attempts? If YES, please provide full details including the nature of the jump i.e. static line or free fal

Yes
No

MOTOR CAR RACING: Do you participate in the sport of motorcar racing? If YES, please provide replies to the following:

Yes
No

How long have you been racing?

What type of competition do you participate in?

Type of motor car/motor cycle? Please include details of engine size and formula

How many races have you participated in over the last twelve months including location of events?

Do you participate in the sport of mountain climbing/mountaineering? If YES, please provide replies to the following

Yes
No

For how many years have you been climbing regularly?

How often do you climb ?

Do you climb alone or with a group/club ?

Do you climb with/without a rope? If YES, please state how often you go climbing, the location and the degree of difficulty.

Yes
No

Are you a member of a mountaineering club? If YES, please provide details

Yes
No

In which of the following areas have you/do you climb?

• Alps (Europe)

Yes
No

• Africa

Yes
No

• Australia/New Zealand

Yes
No

• Himalayas/Karakorum

Yes
No

• North America - Mt McKinley

Yes
No

• North America - elsewhere (please specify)

Yes
No

• UK

Yes
No

• Other areas (please specify)

Yes
No

Maximum height climbed to :

Have you ever suffered from any injury/adverse health condition while climbing?(Like breathlessness , pulmonary edema, blood pressure etc) etc) If Yes please specify)

Yes
No

Have you ever been restricted from climbing by any of the physician? If Yes please provide details

Yes
No

Do you consume or have consumed alcohol ?*

Yes
No

Beer (pint/week)

–+

Hard liquor (peg/week)

–+

Wine (Glass/week)*

–+

Beer since No. of years

–+

Hard Liquor since No. of years

–+

Wine since No. of years

–+

Have you in the past used or do you use any habit forming drugs or narcotics or received any drug abstinence treatment?*

Yes
No

Narcotics

–+

since No. of years

–+

Do you smoke or have smoked?*

Yes
No

Cigarettes / Cigars per day*

–+

Bidis per day*

–+

Ghutka per day*

–+

Pan per day*

–+

Tabacco per day*

–+

Cigarettes/ Cigars since No. of years

–+

Bidis since No. of years

–+

Ghutkha since No. of years

–+

Paan since No. of years

–+

Tobacco since No. of years

–+

Have you stopped smoking?*

Yes
No

Stopped Smoking since No. of years.

–+

Medical Details

Within the past 5 years:

Have you been consulted any doctor / other health practitioner (except for common cold/influenza lasting less than four days)?

Yes
No

Have you been attended by or admitted/advised to be admitted to any hospital/medical facility or availed leave on medical grounds*

Yes
No

Had ECG, X-rays, blood test or any other tests done*

Yes
No

Taken any medication or followed a diet prescribed by a doctor

Yes
No

Have you ever been treated/ hospitalized/ investigated/ diagnosed/ operated for any of the following?

(including but not limited to the specific conditions mentioned under each category)

Chest Pain
Hypertension
Lung Disorder
Diabetes / High BP
Kidney Diseases
Liver Disorder
Cancer
Tropical Disease
Thyroid
Anemia
Nervous Disorder
Ear/Eye/Nose/Throat Disorder
Muscle/Bone/Joints/Limb/Spine Disorder
HIV & STD
Alcohol Treatment
Physical Deformity/Abnormality
Any other Illness/Disorder/Disability
None of Above

Medical Details

Within the past 5 years:

Are you currently taking any medication or undergoing medical treatment OR in the past 5 years, have you been advised to undergo any surgery, medical investigation or medical treatment for any medical condition (other than common cold and flu not lasting more than 5 days?)*

Yes
No

Have you ever been diagnosed or received a treatment for any disease/disorder pertaining to head, brain, eyes, ears, nose, throat, thyroid, heart, lungs, chest, spine, stomach, gall bladder, liver, pancreas, kidneys, intestine, reproductive organ, bones, joints, muscles, skin or blood.*

Yes
No

Have you ever undergone/ been advised to undergo any tests/investigations/surgery/hospitalisation or been diagnosed with/treated for/currently receiving a treatment for any of the following?

Hypertension, heart attack, diabetes, endocrine disorders, anaemia, asthma, tuberculosis, respiratory disease, cirrhosis of liver, jaundice, pancreatitis.*

Yes
No

Paralysis, stroke, motor neuron disease, epilepsy, muscular dystrophy, musculoskeletal disorders, neurological disorders, congenital defect or physical deformity/disability*

Yes
No

Cancer, tumour, anxiety, depression, mental disorder, sexually transmitted disease, HIV, AIDS, hepatitis B or C*

Yes
No

Medical History Details

Disease NameDiagnosis DateTreatment DetailsDosage DetailsDoctor Name Further Test DateAny ComplicationsAdditional Remarks
Add Medical History
  • Family of
  • Relationship
  • Full Name
  • Enter a Age
  • Total Sum Assured (in Lakhs)
  • Health Status
  • Cause of death
  • Occupation
  • Annual Income
Delete
Add a Family Member

Do you have any health related complaints or symptoms e.g. loss of appetite, persistent fever, pain, swelling etc. for which a physician has not been consulted or treatment received?*

Yes
No

Are you pregnant?*

Yes
No

Please specify the number of weeks since pregnant*

–+

Have you or have you ever had, any disorder of the female organs (breasts, ovaries, uterus) or any abnormality of pregnancy or Confinement e.g. caesarean section or miscarriage, high blood pressure, gestational diabetes, etc.?

Yes
No

Have you ever been hospitalised for this condition?

Yes
No

Are you now fully recovered and off all medications?

Yes
No

Physical Details

–+

(Feet)

–+

(Inches)

Kgs

Has there been any variation in weight during the past 6 months ? *

Lifestyle Details

Do you plan to live or travel outside India for more than 30 days?*

Yes
No

Have you in the past 5 years flown as a pilot, co-pilot, pilot instructor, student pilot or do you intend to fly?*

Yes
No

Do you take part or used to take part in any of the following adventurous hobbies/activities:

Sky Diving or Parachuting
Paragliding or Hand gliding
Mountaineering or outdoor rock climbing
Any form of racing
Any other hazardous Activity/hobby
None of Above

PARAGLIDING: Do you participate in the sport of paragliding? If YES, please provide replies to the following:

Yes
No

If you are a member of any professional association, please name the association

Yes
No

What type of glider do you fly? Whether unpowered, self-sustaining or self-launching

Do you expect to participate in any form of competition flying or record attempts or to carry out any prototype testing? If YES, please provide details.

Yes
No

Have you been involved in any accident causing injury to yourself or significant damage to your aircraft? If YES, please provide full details.

Yes
No

PARACHUTING / SKYDIVING: Do you participate in the sport of Parachuting / Skydiving? If YES, please provide replies to the following

Yes
No

For how many years you have been participating in the sport of Parachuting/Skydiving

What licence do you hold? Please provide details

How many jumps you have made till date?

How many jumps do you intend to make in the next twelve months?

Do you expect to participate in any Parachuting/Skydiving competitions or record attempts? If YES, please provide full details including the nature of the jump i.e. static line or free fal

Yes
No

MOTOR CAR RACING: Do you participate in the sport of motorcar racing? If YES, please provide replies to the following:

Yes
No

How long have you been racing?

What type of competition do you participate in?

Type of motor car/motor cycle? Please include details of engine size and formula

How many races have you participated in over the last twelve months including location of events?

Do you participate in the sport of mountain climbing/mountaineering? If YES, please provide replies to the following

Yes
No

For how many years have you been climbing regularly?

How often do you climb ?

Do you climb alone or with a group/club ?

Do you climb with/without a rope? If YES, please state how often you go climbing, the location and the degree of difficulty.

Yes
No

Are you a member of a mountaineering club? If YES, please provide details

Yes
No

In which of the following areas have you/do you climb?

• Alps (Europe)

Yes
No

• Africa

Yes
No

• Australia/New Zealand

Yes
No

• Himalayas/Karakorum

Yes
No

• North America - Mt McKinley

Yes
No

• North America - elsewhere (please specify)

Yes
No

• UK

Yes
No

• • Other areas (please specify)

Yes
No

Maximum height climbed to :

Have you ever suffered from any injury/adverse health condition while climbing?(Like breathlessness , pulmonary edema, blood pressure etc) etc) If Yes please specify)

Yes
No

Have you ever been restricted from climbing by any of the physician? If Yes please provide details

Yes
No

Do you consume or have consumed alcohol ?*

Yes
No

Beer (pint/week)

–+

Hard liquor (peg/week)

–+

Wine (Glass/week)*

–+

Beer since No. of years

–+

Hard Liquor since No. of years

–+

Wine since No. of years

–+

Have you in the past used or do you use any habit forming drugs or narcotics or received any drug abstinence treatment?*

Yes
No

Narcotics Per Day

–+

since No. of years

–+

Do you smoke or have smoked?*

Yes
No

Cigarettes / Cigars per day*

–+

Bidis per day*

–+

Ghutka per day*

–+

Pan per day*

–+

Tabacco per day*

–+

Cigarettes/ Cigars since No. of years

–+

Bidis since No. of years

–+

Ghutkha since No. of years

–+

Paan since No. of years

–+

Tobacco since No. of years

–+

Have you stopped smoking?*

Yes
No

Stopped Smoking since No. of years.

–+

Medical Details

Within the past 5 years:

Have you been consulted any doctor / other health practitioner (except for common cold/influenza lasting less than four days)?

Yes
No

Have you been attended by or admitted/advised to be admitted to any hospital/medical facility or availed leave on medical grounds*

Yes
No

Had ECG, X-rays, blood test or any other tests done*

Yes
No

Taken any medication or followed a diet prescribed by a doctor

Yes
No

Have you ever been treated/ hospitalized/ investigated/ diagnosed/ operated for any of the following?

(including but not limited to the specific conditions mentioned under each category)

Chest Pain
Hypertension
Lung Disorder
Diabetes / High BP
Kidney Diseases
Liver Disorder
Cancer
Tropical Disease
Thyroid
Anemia
Nervous Disorder
Ear/Eye/Nose/Throat Disorder
Muscle/Bone/Joints/Limb/Spine Disorder
HIV & STD
Alcohol Treatment
Physical Deformity/Abnormality
Any other Illness/Disorder/Disability
None of Above

Medical Details

Within the past 5 years:

Are you currently taking any medication or undergoing medical treatment OR in the past 5 years, have you been advised to undergo any surgery, medical investigation or medical treatment for any medical condition (other than common cold and flu not lasting more than 5 days?)*

Yes
No

Have you ever been diagnosed or received a treatment for any disease/disorder pertaining to head, brain, eyes, ears, nose, throat, thyroid, heart, lungs, chest, spine, stomach, gall bladder, liver, pancreas, kidneys, intestine, reproductive organ, bones, joints, muscles, skin or blood.*

Yes
No

Have you ever undergone/ been advised to undergo any tests/investigations/surgery/hospitalisation or been diagnosed with/treated for/currently receiving a treatment for any of the following?

Hypertension, heart attack, diabetes, endocrine disorders, anaemia, asthma, tuberculosis, respiratory disease, cirrhosis of liver, jaundice, pancreatitis.*

Yes
No

Paralysis, stroke, motor neuron disease, epilepsy, muscular dystrophy, musculoskeletal disorders, neurological disorders, congenital defect or physical deformity/disability*

Yes
No

Cancer, tumour, anxiety, depression, mental disorder, sexually transmitted disease, HIV, AIDS, hepatitis B or C*

Yes
No

Medical History Details

Disease NameDiagnosis DateTreatment DetailsDosage DetailsDoctor Name Further Test DateAny ComplicationsAdditional Remarks
Add Medical History

Are you pregnant?*

Yes
No

Please specify the number of weeks since pregnant*

–+

Have you or have you ever had, any disorder of the female organs (breasts, ovaries, uterus) or any abnormality of pregnancy or Confinement e.g. caesarean section or miscarriage, high blood pressure, gestational diabetes, etc.?

Yes
No

Do you have any health related complaints or symptoms e.g. loss of appetite, persistent fever, pain, swelling etc. for which a physician has not been consulted or treatment received?*

Yes
No

Have you ever been hospitalised for this condition?

Yes
No

Are you now fully recovered and off all medications?

Yes
No
Nominee Details

Nominee Details

NameGenderRelationshipNomination%Date of Birth

1)

M F

Name of Appointee

Appointee Gender

M F

Add a Nominee
  • Name
  • Gender
    M F
  • Relationship
  • Nomination Percentage
  • Date of Birth
  • Appointee Name
  • Appointee Gender
    M F
  • Appointee Date of Birth
  • Relationship of Appointee to Nominee
Delete
Add a Nominee

Family Details

Family ofRelationshipFull NameHealth StatusCause of deathAge
Add a Family Member

Family Income Details of

RelationshipOccupationAnnual IncomeTotal Sum Assured (in Lakhs)
Add Member
  • Relationship
  • Occupation
  • Annual Income
  • Total Sum Assured (in Lakhs)
Delete
Add Member
  • Family of
  • Relationship
  • Full Name
  • Enter a Age
  • Total Sum Assured (in Lakhs)
  • Health Status
  • Cause of death
  • Occupation
  • Annual Income
Delete
Add a Family Member

insured

Proposer

Does anybody in your family (father/ mother/ brothers/ sisters) have/ had high blood pressure, cancer, diabetes prior to or at age 60 or any hereditary or chronic disorder ? *

Yes
No
Yes
No

Insurer

Proposer

Have any of the above family members applied for a policy with Edelweiss Tokio Life Insurance Company Limited in the past?

Yes
No
Yes
No
Other Details

Insurance History

Insured

Proposer

Do you have any existing/proposed insurance with Edelweiss Tokio Life Insurance Company and/or with any other Life Insurance Co.

Yes
No
Yes
No

Do you have all the information handy to disclose it at this point of time?

Yes
No
Yes
No

Life Insurance DetailsYear InsuredStatusAcceptance TermSum Assured
Add a Policy
  • Insurance Company
  • Year
  • Status
  • Acceptance Term
  • Sum Assured
Delete
Add Policy

Life Insurance DetailsYear InsuredStatusAcceptance TermSum Assured
Add a Policy
  • Insurance Company
  • Year
  • Status
  • Acceptance Term
  • Sum Assured
Delete
Add Policy

Insure

Proposer

Has any proposal/application for revival on your life or health insurance with Edelweiss Tokio Life Insurance Co. or any other life insurer, ever been declined/postponed/offered/accepted at changed/special terms ?

Yes
No
Yes
No
Insurer
Insurer
Insurer
Proposer
Proposer
Proposer

Have you ever received or do you now receive any disability or critical illness benefits from any insurance company?

Yes
No
Yes
No
Insurer
Insurer
Insurer
Proposer
Proposer
Proposer

Tax Residency

Insurance Repository

Insurer

Do you have an E-Insurance Account No.?

Yes
No

Bank Account Details (For credit of future payout, if any)

COVID Questionnaire

COVID Questionnaire

Have you ever tested positive for the novel coronavirus (SARS-CoV-2/COVID-19)? If yes, provide the date of positive diagnosis. And also details of subsequent tests

Yes
No

If yes, then whether you were hospitalized or Asymptomatic home quarantined

Please Select

If yes, Then whether you suffered Covid-19 related Complications?

Yes
No
Yes
No

If yes, then whether you were hospitalized or Asymptomatic home quarantined

Please Select

If yes, Then whether you suffered Covid-19 related Complications?

Yes
No

Please provide copy of Covid-19 vaccination certificate or provide COVID-19 Vaccination details mentioned below

Have you been vaccinated for COVID19?

Yes
No
Yes
No
Insurer
Insurer
Insurer
Proposer
Proposer
Proposer
0%