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General Information
Basic Information
Nominee Information
Contact Information
Questioner
Policy Number
:
Application Number
:
Project
:
Application Date
:
Dispatch Date
:
Date of Birth
:
National ID
:
Organiser Code
:
Employee Name
:
Designation
:
Organiser Name
:
Organiser Relation
:
---- Select Any One ----
FATHER
MOTHER
SISTER
SON
DAUGHTER
BROTHER
HUSBAND
WIFE
GRAND FATHER
GRAND MOTHER
SELF
NONE
BROTHER IN LAW
SISTER IN LAW
MATERNAL UNCLE
PATERNAL UNCLE
AUNT
GRAND SON
GRAND DAUGHTER
NIECE
NEPHEW
COUSIN
Insured Name
:
Father's/Husband Name
:
Mother's Name
:
Owner Name
:
Owner DOB
:
Owner Sex
:
Insured Sex
:
---- Select Any One ----
Male
Female
Marrital Status
:
---- Select Any One ----
Married
Single
Widowed
Devorce
Separated
Spouse
:
Marriage Date
:
:
Bank Name
:
---- Select Any One ----
AGRANI BANK LTD.
AL-ARAFAH ISLAMI BANK LTD.
AB BANK LTD.
BANGLADESH BANK
BANGLADESH COMMERCE BANK LTD.
BANGLADESH KRISHI BANK
BANGLADESH SAMABAYA BANK LTD.
BANGLADESH DEVELOPMENT BANK LTD.
BASIC BANK LTD.
BRAC BANK LTD.
BANK AL-FALAH LTD:
BANK ASIA LTD.
COMMERCIAL BANK OF CYLON
DHAKA BANK LTD.
DUTCH-BANGLA BANK LTD
EASTERN BANK LTD.
EXIM BANK LTD.
FIRST SECURITY ISLAMI BANK LTD.
HABIB BANK LTD.
HONGKONG & SHANGHAI BANKING CORP.
IFIC BANK LTD.
ISLAMI BANK BANGLDESH LTD.
JAMUNA BANK LTD.
JANATA BANK LTD.
MERCANTILE BANK LTD.
MUTUAL TRUST BANK LTD.
NATIONAL BANK LTD.
NATIONAL BANK OF PAKISTAN.
NATIONAL CREDIT & COMMERCE BANK LTD.
ONE BANK LTD.
PRIME BANK LTD.
PUBALI BANK LTD.
RAJSHAHI KRISHI UNNAYAN BANK
RUPALI BANK LTD.
SHAHJALAL ISLAMI BANK LTD.
SOCIAL ISLAMI BANK LTD
SONALI BANK LTD.
SOUTHEAST BANK LTD.
STANDARD BANK LTD.
STANDARD CHARTERED BANK.
STATE BANK OF INDIA.
THE CITY BANK LTD.
ICB ISLAMIC BANK LTD.
THE PREMIER BANK LTD.
TRUST BANK LTD.
UNITED COMMERCIAL BANK LTD.
UTTARA BANK LTD.
WOORI BANK
NRB COMMERCIAL BANK LTD.
UNION BANK LTD
SOUTH BANGLA AGRICULTURE AND COMMERCE BANK LTD.
MEGHNA BANK LTD.
PADMA BANK LIMITED
MIDLAND BANK LIMITED
NRB BANK LIMITED
MODHUMOTI BANK LIMITED
GLOBAL ISLAMI BANK
SHIMANTO BANK LTD.
BENGAL COMMERCIAL BANK
CITIZENS BANK PLC
Routing Number
:
Account Number
:
Education
:
---- Select Any One ----
JSC
PSC
SSC
HSC
B.COM
M.COM
B.A
M.A
B.SC
M.SC
BBA
MBA(HRM)
L.L.B
BBS
MBS
BSS
MSS
DIPLOMA
B.ED
M.ED
KAMIL
FAZIL
DOP. IN ENG.
BA (HONS)
BSC (HONS)
BCOM (HONS)
MBBS
ACA
ABIA
ALIM
BA(HONS), MA(ENG.)
M PHIL
DAKHIL
EMBA
M.A(ENG.)
MBA(FINANCE)
PGD
MBA(MARKETING)
MSC(MIS)
FLMA
MBA
Annual Income
:
TIN (If any)
:
Religion
:
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ISLAM
HINDU
BUDDHIST
CHRISTIAN
Medical
:
Rural/Urban
:
SL.
Policy Number
Sum Assured
Name of Company
Issued Year
01.
---- Select Any One ----
CHARTERED LIFE INSURANCE COMPANY LTD
02.
---- Select Any One ----
CHARTERED LIFE INSURANCE COMPANY LTD
03.
---- Select Any One ----
CHARTERED LIFE INSURANCE COMPANY LTD
Commencement Date
:
Age Proof Code
:
---- Select Any One ----
NATIONAL ID CARD
S S C CERTIFICATE
S S C TESTIMONIAL
PASSPORT
VOTER LIST
NOTTERY PUBLIC
SELF DECLARATION
SERVICE RECORD
BIRTH CERTIFICATE
OTHERS
DRIVING LICENSE NO
Age
:
Risk Date
:
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
:
Sum at Risk
:
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
:
Only for CEPP Product Info.
Total Premium
:
Assured Child
:
Assured Child Sex
:
Assured Child DOB
:
Assured Child Age
:
Years
Months
Age Proof
:
---- Select Any One ----
NATIONAL ID CARD
S S C CERTIFICATE
S S C TESTIMONIAL
PASSPORT
VOTER LIST
NOTTERY PUBLIC
SELF DECLARATION
SERVICE RECORD
BIRTH CERTIFICATE
OTHERS
DRIVING LICENSE NO
Assured Child Father
:
Assured Child Mother
:
Contingent Nominee
:
Contin. Nominee DOB
:
Contin. Nominee Age
:
Relation To Child
:
---- Select Any One ----
FATHER
MOTHER
SISTER
SON
DAUGHTER
BROTHER
HUSBAND
WIFE
GRAND FATHER
GRAND MOTHER
SELF
NONE
BROTHER IN LAW
SISTER IN LAW
MATERNAL UNCLE
PATERNAL UNCLE
AUNT
GRAND SON
GRAND DAUGHTER
NIECE
NEPHEW
COUSIN
ID
Name
Age
Relation
Share %
---- Select Any One ----
FATHER
MOTHER
SISTER
SON
DAUGHTER
BROTHER
HUSBAND
WIFE
GRAND FATHER
GRAND MOTHER
SELF
NONE
BROTHER IN LAW
SISTER IN LAW
MATERNAL UNCLE
PATERNAL UNCLE
AUNT
GRAND SON
GRAND DAUGHTER
NIECE
NEPHEW
COUSIN
---- Select Any One ----
FATHER
MOTHER
SISTER
SON
DAUGHTER
BROTHER
HUSBAND
WIFE
GRAND FATHER
GRAND MOTHER
SELF
NONE
BROTHER IN LAW
SISTER IN LAW
MATERNAL UNCLE
PATERNAL UNCLE
AUNT
GRAND SON
GRAND DAUGHTER
NIECE
NEPHEW
COUSIN
---- Select Any One ----
FATHER
MOTHER
SISTER
SON
DAUGHTER
BROTHER
HUSBAND
WIFE
GRAND FATHER
GRAND MOTHER
SELF
NONE
BROTHER IN LAW
SISTER IN LAW
MATERNAL UNCLE
PATERNAL UNCLE
AUNT
GRAND SON
GRAND DAUGHTER
NIECE
NEPHEW
COUSIN
---- Select Any One ----
FATHER
MOTHER
SISTER
SON
DAUGHTER
BROTHER
HUSBAND
WIFE
GRAND FATHER
GRAND MOTHER
SELF
NONE
BROTHER IN LAW
SISTER IN LAW
MATERNAL UNCLE
PATERNAL UNCLE
AUNT
GRAND SON
GRAND DAUGHTER
NIECE
NEPHEW
COUSIN
---- Select Any One ----
FATHER
MOTHER
SISTER
SON
DAUGHTER
BROTHER
HUSBAND
WIFE
GRAND FATHER
GRAND MOTHER
SELF
NONE
BROTHER IN LAW
SISTER IN LAW
MATERNAL UNCLE
PATERNAL UNCLE
AUNT
GRAND SON
GRAND DAUGHTER
NIECE
NEPHEW
COUSIN
Correspondence To
:
Present Address
Permanent Address
District Name
:
---- Select Any One ----
DHAKA
FARIDPUR
GAZIPUR
GOPALGANJ
JAMALPUR
KISHOREGANJ
MADARIPUR
MANIKGANJ
MUNSHIGANJ
MYMENSINGH
NARAYANGANJ
NETROKONA
RAJBARI
SHARIATPUR
SHERPUR
TANGAIL
NARSINGDI
BOGURA
JOYPURHAT
NAOGAON
NATORE
NAWABGANJ
PABNA
RAJSHAHI
SIRAJGANJ
CHAPAI NAWABGONJ
DINAJPUR
GAIBANDHA
KURIGRAM
LALMONIRHAT
NILPHAMARI
PANCHAGARH
RANGPUR
THAKURGAON
BARGUNA
BARISHAL
BHOLA
JHALOKATI
PATUAKHALI
PIROJPUR
BANDARBAN
BRAHMANBARIA
CHANDPUR
CHATTOGRAM
CUMILLA
COX'S BAZAR
FENI
KHAGRACHARI
LAKSHMIPUR
NOAKHALI
RANGAMATI
HABIGANJ
MOULVIBAZAR
SUNAMGANJ
SYLHET
BAGERHAT
CHUADANGA
JASHORE
JHENAIDAH
KHULNA
KUSHTIA
MAGURA
MEHERPUR
NARAIL
SATKHIRA
UK
Post Code
:
Email ID
:
Mobile Number
:
Emergency Mobile No.
:
Passport Number
:
Business Address
Owner Address
Enter your height
Enter your Weight
Do you smoke cigarettes or any other forms of tobacco?
Have you had any physical defects or health impairments?
Have you had treatment of respiratory disease?
Have you had treatment of high blood pressure, chest pain, disease of the heart?
Have you had treatment of Ulcer, hepatitis, liver or gall-bladder disease?
Have you had treatment of any disorder of the genito-urinary system?
Have you had treatment of mental or nervous disorder?
Have you had treatment of Diabetes, cancer, tumor or any other severe injury?
Have you had treatment of any eye, hearing or speech disorder?
Have you had treatment of any surgery?
Have you received any treatment with AIDS, any AIDS related condition or sexually transmitted diseas?
Have you ever been diagnosed, treated for, had surgery for, tested positive for birth defect?
Are you currently pregnant?
How many months are you pregnant?
Have you ever had any complication at children or disorder of the breast or female organs?
Do you have any children? If yes then how many