SECTION C — LIFE ASSURED DETAILS (if different from proposer)
Full Name
Relationship with Proposer
Date of Birth
Age
Gender
Occupation
Annual Income (₹)
PAN Number
SECTION D — NOMINEE DETAILS
Nominee Full Name
Relationship with Life Assured
Date of Birth
Share (%)
Appointee Name (if nominee is minor)
Appointee Relationship
SECTION E — ADDRESS DETAILS
Residential Address
City
State
PIN Code
Type of Residence
Years at Current Address
SECTION F — MEDICAL & LIFESTYLE DETAILS
Do you have any of the following? (tick if YES)
Height (cm)
Weight (kg)
BMI (if known)
Do you smoke?
Do you consume alcohol?
Any hazardous occupation / hobby?
SECTION G — VEHICLE DETAILS (Car / Bike Insurance only)
Vehicle Registration No.
Make & Model
Year of Manufacture
Engine Number
Chassis Number
Fuel Type
Seating Capacity
Current IDV / Insured Value (₹)
Previous Policy No. (if renewal)
Previous Insurer (if renewal)
No Claim Bonus % (if applicable)
Any Claims in Last 3 Years?
DECLARATION & SIGNATURE
I/We hereby declare that all statements and answers given in this proposal form are true, complete and correct to the best of my/our knowledge and belief. I/We understand that this proposal shall form the basis of the insurance contract. I/We authorise PaisePe Financial Services and its licensed insurer partners to obtain medical or other information from any doctor, hospital or other organisation. I/We understand that any misrepresentation or concealment of material facts may render the policy voidable or void.
Place
Date
PROPOSER SIGNATURE / THUMB IMPRESSION
DOCUMENTS REQUIRED (attach self-attested copies)
PAN Card
Aadhaar Card
Passport / Voter ID / Driving Licence (Age proof)
Passport size photograph (2 nos.)
Income proof — salary slip / ITR (for Life & Term)
Medical reports (if any pre-existing condition)
Vehicle RC & previous policy copy (Car / Bike)
No Claim Bonus certificate (if renewal)
Bank cancelled cheque (for ECS / premium auto-pay)
PaisePe · hello@paisepe.com · www.paisepe.comForm Version 1.0 · 2026
