Date: ____/______/20 Customer Information FormName: Spouse:

Address: E mail:

Date of Birth:Spouse’s D.O.B.:

Marriage Anniversary:

Profession:

Business Service Self Employed Professional Retired Other

Would you like to conduct a goal gap analysis for you :

Yes No

Would you like us , to contact /send you informative e-mailers :

Yes No

How do you manage your investments/ financial matters:

Yourself By an agent By a professional financial Advisor

Do you have an appropriate Health Insurance cover in place:

Yes No If Yes, mention Sum Assured

After the presentation, do you consider yourself financially secure and confident about your financial life:

Yes NoAny other comments ,which might help us to understand you better:

Signature ______________________________