5/25/23, 12:24 PM ICICI Prudential Life Insurance

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YOUR APPLICATION NUMBER IS OS21524568 95%

Sales Details

Agent Code FSC Code

01359703 01373445
Bank Branch
MLCA ZK49
Source Opportunity ID
MLCA 999999

Cafos Code LAN No

14596 12345678

CSR LIM Code SP Code

5059913 SP0579458889

Product Details

Product Name Premium Paying Term

ICICI Prudential Future Perfect 7

Frequency Policy Term

Yearly 12
Sum Assured(₹) Premium(₹)
5,00,000 52,251

Details of RAMANAND MORESHWAR KALASKAR

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Gender Father's Name

MALE MORESHWAR HARIBHAO KALASKAR

Mother's Name Spouse Name

ALKA MORESHWAR KALASKAR PRANALI RAMANAND KALASKAR

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Date of Birth Marital Status

08-Jun-1987 Married
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Occupation Education
Salaried
YOUR APPLICATION NUMBER IS OS21524568 Post Graduate
95%
Annual Income (₹) Organisation
8,00,000 Others
Organisation Name Description Organisation Type
SASWAD MUNICIPAL COUNCIL Government

Are you engaged in any of the mentioned industries(Export, No

Jewellery, Real Estate, Scrap Dealing, Shipping, Stock Broking &
Agriculture)
Income Tax Proof PAN
PAN(Permanent Account Number) CQQPK3914F

Objective of buying policy Age Proof

Saving PAN card
ID Number Address Proof
CQQPK3914F Masked Aadhaar Card Copy
Identity Proof
Masked Aadhaar Card Copy

Politically Exposed No

Have you ever been or currently being investigated, charge No

sheeted, prosecuted or convicted or acquittal or having pending
charges in respect of any criminal/civil offences in any court of law
in India or abroad? If Yes, give details

Do you have an Electronic Insurance Account? No

E-insurance Account Repository

NSDL National Insurance Repository

Would you like to share your portfolio/fund details with your Yes
Advisor/Agent

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Premium paid by a person other than Proposer (If yes, please No

submit third party declaration and Payer's KYC) Logout

YOUR APPLICATION NUMBER IS OS21524568 95%

Nominee Details

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Full Name Relationship with Life Assured

PRANALI RAMANAND KALASKAR WIFE

Nominee's Date of Birth

17-Nov-1994

Previous Policy Details

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Details of Life Insurance/Mediclaim/Health/Personal Accident No

policies of the life to be Assured held/ applied with ICICI Prudential/
other companies.

Contact Details

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Mailing/Communication Address
FLAT NO 214 VITTHAL VIHAR, BRAMHAN AALI SASWAD, TQ PURANDAR DIST, PUNE,
412301, MAHARASHTRA,INDIA

Permanent Address
S/O MORESHWAR KALASKAR, CHAUGAN, CHAUGAON, CHAUGAON, CHANDRAPUR,
BRAHMAPURI, CHANDRAPUR, 441206, MAHARASHTRA,INDIA

Life Assured Mobile Number

8275393337

Email ID
[email protected]
Nationality Resident Status
INDIAN RESIDENT INDIAN

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Health Details of RAMANAND MORESHWAR KALASKAR
YOUR APPLICATION NUMBER IS OS21524568 95%
Height in Ft Height in cm
5 feet 8 inches 173

Weight in kg
75

Do you consume or have ever consumed narcotics? No

Do you consume or have ever consumed tobacco? No

Do you consume or have ever consumed alcohol? No

Have you ever suffered or being diagnosed with or been treated for No
any of the following?

Are you employed in the armed (navy, airforce, army), para military No
or police forces? (If yes, please provide Rank, Department/Division,
Date of last medical & category after medical exam)

Do you have any Congenital Defect/Abnormality/Physical No

Deformity/Handicap?

Family details of the life assured(include parents/sibling) Are any of No

your family members suffering from /have suffered from/have died
of heart disease,Diabetes Mellitus, cancer or any other
hereditary/familial disorder, before 55 years of age.if yes please
provide details below.

Have you undergone or been advised to undergo any No

tests/investigations or any surgery or hospitalized for observation
or treatment in the past?

Did you have any ailment/injury/accident requiring No

treatment/medication for more than a week or have you availed
leave for more than 5 days on medical grounds in the last two
years?

Is your occupation associated with any specific hazard or do you No

take part in activities or have hobbies that could be dangerous in
any way? (e.g. occupation- chemical factory, mines, explosives,
radiation, corrosive chemicals & hobbies - aviation other than as a
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fare paying passenger, shipping, diving, mountaineering, any form

of racing etc.) Logout

Have you lost weight of 10 kgs or more in the last six months? No
YOUR APPLICATION NUMBER IS OS21524568 95%

Have you ever been tested positive for COVID 19? No

In the last 1 month have you or any of your family member been No
self-isolated with symptoms on medical advice?(excluding
mandatory government orders to remain at home)

In the last 1 month did you have persistent cough, fever ,sore No
throat, nausea, vomiting ,diarrhea, difficulty in breathing ,loss of
smell and taste any other symptoms of coronavirus (COVID-19)
and advised to do a Covid test or you/your family member have
been in contact with an individual suspected or confirmed�to have
COVID-19?

Do you work in an occupation like health care worker/Corona No

warrior Include (General Practitioners, Doctors, Hospital Doctors,
Surgeons, Therapists, Nurses, Pathologist, paramedics,
Pharmacist, Ward helpers, Individuals working in Hospitals/ Clinics
having novel coronavirus (SARS-CoV-2/COVID-19) Ward ?) where
you have a higher risk to get in close contact with COVID-19
patients or with coronavirus contaminated material?

Have you been vaccinated for COVID19? No

Are you currently residing outside of India No

Have you travelled abroad in past 14 days No

Do you intend to travel abroad in next 3 months No

Would you like to fill the Health Declaration Form?

Payout Details

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5/25/23, 12:24 PM ICICI Prudential Life Insurance

Name of Account Holder Bank Account Number

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RAMANAND MORESHWAR KALASKAR 060610110012458

Account
YOUR Type
APPLICATION NUMBER IS OS21524568 IFSC Code
95%
Saving BKID0000606

MICR Code Bank Name

411013036 Bank Of India .. BKID0000606

Standing Instruction (ECS) Opted Amount

Yes 52,251

Frequency Debit Type

As and when presented Maximum Amount
Period
Until Cancelled

Please confirm if you want to enable communication on whatsapp.


Yes   No

I RAMANAND MORESHWAR KALASKAR, have gone through above mentioned

benefit illustration / key feature document and terms & conditions. I have read and
understood features of this product and I provide my consent to ICICI Prudential Life
Insurance Company Limited to process my insurance application.

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