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Insured Details / Proposer Details
CKYC Verification
ID Type
*
SELECT
PAN CARD
VOTER ID
DRIVING LICENSE
AADHAR CARD
EXISTING CKYC NUMBER
EXISTING MANUAL CKYC NUMBER
ID No
*
Customer DOB
*
Customer Mobile No
*
Customer E-Mail Id
Is there any change in my existing KYC details which I have already shared. Click
YES
NO
CKYC Unique Transaction No
*
CKYC No
*
CKYC Customer Contact No
CKYC Customer E-Mail Id
Proposer Details
Proposer Details
*
Date of Birth
*
Gender
*
SELECT
Male
Female
E-Mail Id
*
Mobile No
*
Address Line 1
*
Address Line 2
*
State
*
SELECT
55
69
ANDAMAN AND NICOBAR ISLANDS
ANDHRA PRADESH
ARUNACHAL PRADESH
ASSAM
BIHAR
CHANDIGARH
CHHATTISGARH
DADRA AND NAGAR HAVELI
DAMAN & DIU
DAMAN AND DIU
DELHI
GOA
GUJ
GUJARAT
HARYANA
HIMACHAL PRADESH
INDIA
JAMMU AND KASHMIR
JHARKHAND
KAPURTHALA
KARNATAKA
KATMANDU
KERALA
LADAKH
LAKSHADWEEP
MAD
MADHYA PRADESH
MAHARASHTRA
MANIPUR
MEGHALAYA
MIZORAM
Maharashtra
NAGALAND
ODIS
ODISHA
ORISSA
PONDICHERRY
PUNJAB
RAJASTHAN
SIKKIM
TAMIL NADU
TELANGANA
TRIPURA
UTTAR PRADESH
UTTARAKHAND
UTTARPRADESH
WEST BENGAL
City
*
Pin code
*
Enter valid pin code
If Address is same as above, please select here
Present Address Line 1
*
Present Address Line 2
*
State
*
SELECT
55
69
ANDAMAN AND NICOBAR ISLANDS
ANDHRA PRADESH
ARUNACHAL PRADESH
ASSAM
BIHAR
CHANDIGARH
CHHATTISGARH
DADRA AND NAGAR HAVELI
DAMAN & DIU
DAMAN AND DIU
DELHI
GOA
GUJ
GUJARAT
HARYANA
HIMACHAL PRADESH
INDIA
JAMMU AND KASHMIR
JHARKHAND
KAPURTHALA
KARNATAKA
KATMANDU
KERALA
LADAKH
LAKSHADWEEP
MAD
MADHYA PRADESH
MAHARASHTRA
MANIPUR
MEGHALAYA
MIZORAM
Maharashtra
NAGALAND
ODIS
ODISHA
ORISSA
PONDICHERRY
PUNJAB
RAJASTHAN
SIKKIM
TAMIL NADU
TELANGANA
TRIPURA
UTTAR PRADESH
UTTARAKHAND
UTTARPRADESH
WEST BENGAL
City
*
Pin code
*
Enter valid pin code
Please select your Annual Income
*
Select
Less than 5,00,000
5,00,000 to 10,00,000
10,00,000 to 20,00,000
20,00,000 to 50,00,000
Greater than 50,00,000
Bank Name
*
Enter valid bank name
IFSC Code
*
Enter Alpha-Numbers Only
Pan Number/Form 60 Details:
*
Pan Number
Form 60
Additional Information
Please state the devices you commonly use
Mobile Phone
Laptop
Tablet
Smart-watch
Others
Please confirm if you have anti-virus software installed on your commonly used devices?
Please confirm if you maintain confidentiality of your passwords and regularly change your passwords
Please confirm if you do data back up after every 14 calendar days
SECURITY INCIDENT AND LOSS HISTORY: Are you or your family (if applicable) aware of any incidents or circumstances (currently or in the recent past) which is likely to lead to you suffering a loss or a claim being made against you which would be covered under any of the sections of this policy you are applying for
Are you a Politically Exposed Person or a relative of PEP? (Definition of PEP: Politically Exposed Persons (PEPs) are individuals who have been entrusted with prominent public functions by a foreign country, including the heads of States or Governments, senior politicians, senior government or judicial or military officers, senior executives of state-owned corporations and important political party officials.)
Data Privacy (I/We authorize the Company to share / verify the information provided by me/us pertaining to my proposal with rating agencies, third parties or services providers for the purpose of underwriting the proposal, issuance, servicing and claims settlement of the policy, there after. I hereby consent to and authorize Universal Sompo General Insurance Company Limited (“Company”) and its representatives to collect, use, share and disclose information provided by me, as per the Privacy policy of the Company. Company or its representatives are also hereby authorised to contact me (including overriding my registry on NCPR/NDNC and/or under any extant TRAI regulations) and / or notify about the services being rendered by the Company.).
Any Disability
Disability Description
Enter valid Disability Description
Insured/Member Details
Name of Insured
*
Date of Birth
*
Gender
*
Select
Male
Female
Please select your Occupation
*
Select
Salaried
Business
Others
Relationship
*
Self
Operating System Used
*
Select
Windows
Android
Mac OS
Other
Name of Nominee
*
Address of the Nominee
*
Nominee Date of Birth
*
NomineeRelation
*
SELECT
Self
Spouse
Son
Daughter
Father
Mother
Self
Spouse
Brother
Sister
Father
Mother
Son in law
Daughter in Law
Brother in Law
Sister in law
Father in law
Mother in law
Grand Father
Grand Mother
Nephew
Niece
Other
Legal Heir
Son
Daughter
Grand Son
Grand Daughter
Appointee Name (If Nominee is minor)
Enter valid Appointee Name
Appointee Relationship
SELECT
Self
Spouse
Son
Daughter
Father
Mother
Self
Spouse
Brother
Sister
Father
Mother
Son in law
Daughter in Law
Brother in Law
Sister in law
Father in law
Mother in law
Grand Father
Grand Mother
Nephew
Niece
Other
Legal Heir
Son
Daughter
Grand Son
Grand Daughter
Terms and Conditions
I hereby request and authorize the bank to debit my account on yearly due dates with the applicables renewal premium