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LIFE
INSURANCE CORPORATION OF
Divisional Office_______________
Branch Code____________
SPECIAL QUESTIONNAIRE TO BE COMPLETED IN RESPECT OF NRIs
Proposal No.______________
A. To be filled in by the Dean/principal in respect of students and Employer in respect of employed persons
| Name of the proposer |
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| When did he join your college/university/firm? |
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| Date of Birth and age |
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| Educational qualification |
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| General appearance |
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| Any identification mark/s? |
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| Does he have any physical deformity? – (impaired sight or hearing, physical impairment or mental retardation) |
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| His professional status (type of duties performed) |
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| Has he remained absent from college / duties on medical ground? If so, period of absence and reasons thereof |
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| What are his habits / hobbies? Does he consume tobacco, snuff or other narcotic substances in any form, alcoholic drinks? |
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| His per month salary / stipend / teaching allowance |
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| Results of any routine medical check-up |
B. To be filled in by the Personal Physician in respect of self-employed persons
| Name of the proposer |
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| Since how long do you know the proposer? |
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| Age of the proposer |
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| General appearance |
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| Any identification mark/s? |
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| Does he have any physical deformity? – (impaired sight or hearing, physical impairment or mental retardation) |
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| Has he taken any treatment from you? Yes/ No If Yes, full details and the period of treatment |
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| What are his habits / hobbies? Does he consume tobacco, snuff or other narcotic substances in any form, alcoholic drinks? |
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| Any information about his financial status? |