Life Insurance Step 03 – Tpllife

Life Insurance Step 03demo.deadhappy2024-02-16T10:29:06+00:00

Step 1 of 5

20%

This field is hidden when viewing the form

First Name(Required)

This field is hidden when viewing the form

Last Name(Required)

This field is hidden when viewing the form

YYYY-MM-DD(Required)

YYYY dash MM dash DD

This field is hidden when viewing the form

AGE(Required)

This field is hidden when viewing the form

Gender(Required)

This field is hidden when viewing the form

Mobile Number(Required)

This field is hidden when viewing the form

Email(Required)

This field is hidden when viewing the form

Current Height (not use)(Required)

This field is hidden when viewing the form

Current Weight (not use)(Required)

This field is hidden when viewing the form

Occupation (not use)(Required)

This field is hidden when viewing the form

Monthly Income (not use)(Required)

This field is hidden when viewing the form

Feet (not use)

This field is hidden when viewing the form

Whole (not use)

This field is hidden when viewing the form

Decimal (not use)

Questions

Do you intake Tobacco or Nicotine in any form?

Do not worry, it's a confidential information!

Answer No. 1(Required)

Yes

No

Questions

What's your intake of Tobacco or Nicotine in any form?

Help us identify your consumption pattern

Answer No. 2 with 4 options(Required)

0-5 times

5 to 10 times

10 to 20 times

Can't specify

Questions

Do you consume Alcohol?

Do not worry, it's a confidential information!

Answer No. 3(Required)

Yes

No

Questions

What's your routine for consuming alcohol?

Help us identify your consumption pattern

Answer No. 4 with 2 options(Required)

Social Drinking

Regular Drinking

We are just getting done, hang on!

Have you been diagnosed before or are currently suffering from any of the following diseases?

Disease

Cancer

Kidney Disease

Stroke

Deformity or Disability

Nervous Disorders (Depression, Psychiatric Disorder)

Bleeding Disorder

Anaemia

Paralysis

Musculoskeletal Disorders

Chronic Obstructive Pulmonary Disease

High Blood Pressure

Thyroid Disorder

Liver Cirrhosis/Liver Failure

Heart Failure

Ischemic Heart Disease

Heart Valvular Disease

Cardiac Arrhythmia

Hepatitis B

Hepatitis C

Diabetes

Coronary Artery Disease

Heart Attack

Other options

I am unaware

I am healthy

This field is hidden when viewing the form

Qusetion No.5 answer(Required)

This field is hidden when viewing the form

Term 1 Ratio

This field is hidden when viewing the form

Term 2 Ratio

This field is hidden when viewing the form

Term 3 Ratio

This field is hidden when viewing the form

Term 4 Ratio

This field is hidden when viewing the form

Term 5 Ratio

This field is hidden when viewing the form

Term 6 Ratio

This field is hidden when viewing the form

Term 7 Ratio

This field is hidden when viewing the form

Term 8 Ratio

This field is hidden when viewing the form

Term 9 Ratio

This field is hidden when viewing the form

Term 10 Ratio

This field is hidden when viewing the form

Term 11 Ratio

This field is hidden when viewing the form

Term 12 Ratio

This field is hidden when viewing the form

Term 13 Ratio

This field is hidden when viewing the form

Term 14 Ratio

This field is hidden when viewing the form

Term 15 Ratio

This field is hidden when viewing the form

Term 16 Ratio

This field is hidden when viewing the form

Term 17 Ratio

This field is hidden when viewing the form

Term 18 Ratio

This field is hidden when viewing the form

Term 19 Ratio

This field is hidden when viewing the form

Term 20 Ratio

This field is hidden when viewing the form

Term 21 Ratio

This field is hidden when viewing the form

Term 22 Ratio

This field is hidden when viewing the form

Term 23 Ratio

This field is hidden when viewing the form

Term 24 Ratio

This field is hidden when viewing the form

Term 25 Ratio

This field is hidden when viewing the form

Tax Amount

Code of Conduct | Privacy Policy

Great Job!

Words cannot express how grateful we are for your
willingness to volunteer

Thank you!

You now have the option to swiftly navigate to the Health Declaration
form or continue onward with Inshu Charity.