Commencement Date	:		Date of Birth	:
Insured Sex	:	---- Select Any One ----Male Female	Marrital Status	:	---- Select Any One ----Married Single Widowed Devorce Separated
Owner DOB	:		Owner Sex	:
Age	:		Product Name	:	---- Select Any One ----01 - C-3PP 02 - C-5PP 03 - CEP-1 04 - CEP-2 05 - CMBP 08 - CSP 09 - CPP 10 - CEP 11 - CCP 12 - CMSP - BRONZE 20 - CEP PLUS 21 - C-3PP PLUS 22 - CMSP 23 - CMSP - GOLD 24 - CHB 25 - CDB 26 - C-5PP PLUS 27 - CMBP PLUS 28 - CEP-1 PLUS 29 - CDB PLUS 30 - CMSP - CLASSIC 31 - CHARTERED NIRAPATTA 32 - CSPC 33 - CSPC PLUS 34 - CHARTERED AL-BARAKAH MSP 35 - CHARTERED AL-BARAKAH SINGLE PLAN (DOUBLE BENEFIT) 36 - CHARTERED AL-BARAKAH SINGLE PLAN 37 - AL-BARAKAH SINGLE PLAN PLUS (WITH PROFIT) 38 - AL-BARAKAH SINGLE PLAN PLUS (WITHOUT PROFIT) 39 - CHARTERED AL-BARAKAH HAJJ BIMA 40 - CHARTERED AL-BARAKAH 3PP 41 - CHARTERED AL-BARAKAH MANPOWER PLAN 42 - CHARTERED AL-BARAKAH 3PP PLUS 43 - CHARTERED AL-BARAKAH MSP - GOLD 44 - CHARTERED AL-BARAKAH CEP PLAN 45 - CHARTERED AL-BARAKAH CEP PLUS 46 - CHARTERED SAMRIDHI PLAN 47 - CHARTERED CRITICAL ILLNESS PROTECTION PLAN 48 - CHARTERED AL-BARAKAH 5PP 49 - CHARTERED AL-BARAKAH 5PP PLUS
Term	:		Premium Term	:
Sum Assured	:
Mode of Payment	:		Life Prem	:
Occupation	:	---- Select Any One ----DRIVER BUSINESS OTHERS SERVICE HOUSEWIFE TEACHER NURSE NON COMMISSION ARMY CONSTRUCTION LABOUR FINANCIAL ASSOCIATE SECURITY GUARD CNG DRIVER UNIT MANAGER BRANCH MANAGER FARMER IMAM	Occupation Extra	:
Female Extra	:		Health Extra	:
Lien Term	:		Lien Percentage	:
SL No. Supplimentary Name Supplimentary Sum Assured Supplimentary Premium 1. ---- Select Any One ----ADB, WP, CI 50% FEMALE ADB PDAB WPD AD & D CIC ADB, WP, CI 100% MALE ADB, WP, CI 50% MALE ADB, CI 50% HOUSEWIVES ADB, WP, CI 100% FEMALE FPR IBR DPR AMR (MAXIMUM 20% OF FA) 2. ---- Select Any One ----ADB, WP, CI 50% FEMALE ADB PDAB WPD AD & D CIC ADB, WP, CI 100% MALE ADB, WP, CI 50% MALE ADB, CI 50% HOUSEWIVES ADB, WP, CI 100% FEMALE FPR IBR DPR AMR (MAXIMUM 20% OF FA) 3. ---- Select Any One ----ADB, WP, CI 50% FEMALE ADB PDAB WPD AD & D CIC ADB, WP, CI 100% MALE ADB, WP, CI 50% MALE ADB, CI 50% HOUSEWIVES ADB, WP, CI 100% FEMALE FPR IBR DPR AMR (MAXIMUM 20% OF FA) 4. ---- Select Any One ----ADB, WP, CI 50% FEMALE ADB PDAB WPD AD & D CIC ADB, WP, CI 100% MALE ADB, WP, CI 50% MALE ADB, CI 50% HOUSEWIVES ADB, WP, CI 100% FEMALE FPR IBR DPR AMR (MAXIMUM 20% OF FA) 5. ---- Select Any One ----ADB, WP, CI 50% FEMALE ADB PDAB WPD AD & D CIC ADB, WP, CI 100% MALE ADB, WP, CI 50% MALE ADB, CI 50% HOUSEWIVES ADB, WP, CI 100% FEMALE FPR IBR DPR AMR (MAXIMUM 20% OF FA) 6. ---- Select Any One ----ADB, WP, CI 50% FEMALE ADB PDAB WPD AD & D CIC ADB, WP, CI 100% MALE ADB, WP, CI 50% MALE ADB, CI 50% HOUSEWIVES ADB, WP, CI 100% FEMALE FPR IBR DPR AMR (MAXIMUM 20% OF FA)
Policy Option	:		Supp. Total Premium	:
			Total Premium	: