Edelweiss Tokio Life Insurance
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-------Life Assured Details-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Customer Name * Gender
Date Of Birth * Age of Customer
Tobacco Consumer
LA Occupation  
LA Education Evidence Income (of Proposer)
-------Proposer Details---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Proposer Name Proposer Gender
Date Of Birth of Proposer Age of Proposer
-----To be entered for Annuity Plan----------------------------------------------------------------------------------------------------------------------------------------------------------------------
Name of Secondary Annuitant Gender ( Secondary Annuitant )
Date of Birth of Secondary Annuitant Age of Secondary Annuitant

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