KARNATAKA GOVERNMENT INSURANCE DEPARTMENT

LIFE INSURANCE PROOPOSAL FORM (Compulsory LIfe lnsurance)

BASIC DETALS
Date of submission of proposal: 28-09-2024
Proposal No.:20221107154918
Proposer Name: ESUNILKUMAR ( od da)
Father Name: E BHASKAR (® e0 U)
Gender: Male
Date of Birth: 22-09-1983 QR Codc
Place ofBirth: BASAPUR
Adlress of the District Insurance ofice: DISTRICT INSURANCE OFFICER,
Residential Address: EBHASKAR NEAR MSPL HOSALINGAPUR TÌ KOPPAL.DIST KARNATAKA GOVERNMENT INsURANCE DEPARTMENT, KOPPAL
KOPPAL
Present Working Office: GOVERNMENT HIGH SCHOOL, SRIRAMNAGAR
Pin Code: 583233
Mobile No.: 9035074528 Date of entry into Government Service: 03-07-2008
E-Mail: [email protected] Permanent / Temporary: Permanent
PAN Number: AAIPE1067B Present Designation: SECONDARY SCHOOL ASSISTANT MASTER/MISTRESS
Grvup:
GRADE II
Marital Status: Marricd Present Pay Scale: 37900.00 - 70850.00
Spousc Namc: JSWATIIPRIYA ( 3ai)
Divorce /Remarried: N/A

Initial Deposit Details:

Challan Reference No Date Amount (Rs).
KDO924801128522834 28-09-2024 3000

KGID DETAILS

KGID Poliey Number Datc of risk Premium amount

2275161l 10/20/2008 800.00
2883060 7/23/2018 2900.00
Application Ref Number Date of Payment Initial Deposit

20221107154918 3000

FAMILY DETAILS

Alive / Is Sibling Health Condition Date of Death Death Reason

Nume Relation Date of Birth Ap
Dead Married?
E BHASKAR Father 01-07-1964 60 Alive NIA GOOD CONDITION
E PRAMILA Mother 01-06-1966 58 Dcad N/A 25-03-2003 BAD HEALTH
JSWATHIPRIYA Spousc 13-12-1991 33 Alive NIA GOOD CONDITION
: SUPRIYA Daughter 23-04-2011 Alive N/A GOOD HEALTH
E KHUSHI Daughtcr 26-10-2017 7 Alive N/A GOOD CONDITION

Number of Brother's :0 Number of Sister's : 0

Number of Children's : 2
 NOMINEE DETAILS

Name Nomince Age Relation Guardian Name Guardian Relation

ISWATHIPRIYA 33 Spouse

PERSONAL DETAILS

Is your hcalth in good

:Yes
condition now?

Details regardng any

reatment taken for
nore than l week for
(b) No
any illness or
undergonc any surgery
in last 3 years
Details regarding any
absencc from work
due to illness during
(C) : No
the last 3 years, state
when, how long and
for which disease.
Have you ever
suflered from discases
of stomach(Digestive
system),Lungs, Urinary
tract, Brain, Nerves or
any other bodily parts,
Diabctes.
(d) Tuberculosis, Hyper or No
Hypo tension(high or
low B.P), Cancer.
Epilepsy(Epileptie
seizures), Leprosy.
Hernia, Hepatitis-B or
HIV AIDS? If so
providc dctails

Do you drink winc,

spirits or malt liquors?
Are you addicted to
the usc of any narcotic
(e) drugs like opium, : No
cocainc, etc. If so,
give particulars, Do
you smoke tobacco? If
so, lo what extet?
Have you had any
other illnesses
(0 considercd by you to No
be importunt or not? If
so, give details.
Height
[ems]
Your exact height and :56
(2)
weight Weight
[kgs)
:72

DECLARATION

1. completcly,
IMHMs/Kunmari ESUNIL KUMAR, who has put forward the compulsory life insurance proposal, declare that Ihave come to know all the questions in this propsal
and havc provided them with factual information.

2.1Fthere is any diference in my hcalth condition, in thc interim period betwecn the datce of submission and the date of acoeplance of the proposal, Iwill notify the same to
the insurance department in writing.
3. l am aware that the information provided by me is the basis for (he insurancc contract. The insurancc contract will be incffective and the premiums paid by mc will be
to be incorrect.
forfeited by the g0vernment if the information provided by me are found

4. Iagrec to all the conditions of the Compulsory Life Insurance Rules.

Date:
Place: Signature r he Proposer and Designation
ASsT, TEACHER.
 CERTIFCATION BY (OFFCIAL SUPERIOR
LIhooser has availed lcave on mcdical grounds during the last 3 vears, as mentioncd below.
SL.No From Date |To Date |Duration Reason

(An attested copy of medical certificate, if provided, has to be submitecd along with the
proposal.)
l attest that the infomation provided Basic Details hus been serutinized und is tue and also thut the proposer has provided factual infornation for all the questions above

Date: Seal &Signaure of thho

Place: (Drawing&0on ota
Designation and address including pincodd

Note:

1. Govemment servant who have not crosscd the age of 50 years are only eligible for submitting this proposal.
2. If theproposer is aged abovc 40 ycars or if the monthly premium of the proposed policy is more than Rs. I000/- in such casc, the proposer has to under go a medical
cxamination and the medical examiner's report has to be submitted along with the proposal.
3. If the proposer ccascs to be in government service on the date of acceptance of his proposal by the departmcnt the proposal stands cancelled automatically.