Proposal Details for Proposal No PR-99428 Policy & Payment Details
Life Insurance : CI18
Order Reference :PR-99428
Transaction ID : 141778254205
Transaction Status : Failed
Amount : PKR 20,982.00
Response Code : Request processed successfully
Card Number :
Approval Code :
Applicant Details
Insured Name : Hassan Ali Khan
Cnic/Passport : 5406456458789
Father/Spouse Name : Farah Hassan
Mother's Name : Mehmooda
Date of Birth : 15/12/1988
Age : 26
Nationality : Pakistani
Education : UNDERGRADUATE
Gender : Male
Smoker : No
Marital Status : M Life Cover
Policy Cover : PKR 1,850,000.00
Payment Frequency : Annual
Policy Term : 5
Premium Duration : 5
Annual Premium : PKR 20,982.00
Fee Applied : PKR 300.00
Policy Riders Total Premium
Total Premium : PKR 20,982.00 Contact & Residence Details
Email Address: sdASD@hotmail.com
Mobile Number : +923216480648
Landline number : House Number : 49/6
Street / Lane : Nazimabad
Locality /Area : Karachi
Landmark : behind bahria college
Country: Pakistan Province/ State : Sindh
City / Town : Karachi
Professional & Financial Details
Industry Type : Commerce, Finance, Insurance, Professions, Services & Trading
Occupation Type : Insurance & Microinsurance
Organization Type : Insurance Agent
Designation: SEO
Name of Organization : Jubilee LIfe Annual Income : PKR 15,000,000.00
Income- Tax Year : 2015.00000
Residence Status :
Working Years : 16
Age Proof : Form B (Bey) - NADRA
Address Proof : Computerized National Identity Card (CNIC)
Photo ID Proof : Computerized National Identity Card (CNIC)
Income Proof : Payslip / Salary Statement (not older than 30 days)
Last Travel Professionally Country :
How Often : 0
Last Ago : 0 Previous & Concurrent Insurance Details
Existing Insurance : No Insurance Proposal (Application) : No Company Name :
Quotation Number :
Application Date:
Insurance Type :
Basic Benefit Amount : PKR 0.00
Status : Select Status
Status (Reason) : Height, Weight, Habits, Avocation & Hazardous Activities
Height : 6-1
Weight : 80
Weight Gain : 0
Weight Loss : 0
Consume Tobacco : No
Consume Alcohol : No
Consume Drugs/Medicines : No Drugs/Medicines Details : Do you participate or intend to participate in any dangerous / hazardous pursuits or activities, including but not limited to, diving, motor racing, aviation, mountaineering, paragliding, skydiving, parachuting, potholing, bungee jumping, boxing, wrestling, martial arts etc.?: No Do you engage or have you ever engaged (in any capacity) or has any family member or close associate engaged in political or religious-political activity? : No Do you have or have you ever had any enmity with anyone whomsoever? Are you involved or were you ever involved in any civil or criminal litigation or police case in any court of law or with any law enforcing agency? Has any FIR been registered against you? : No Beneficiary Details
Name Of Guardian :
Name of Nominee :
Age of Guardian : 0
CNIC / Citizenship Number of Guardian :
Relationship of Guardian with Nominee : Spouse
Nominee Name
Date of Birth of Nominee
Relationship of Nominee with Life Proposed
Percentage Share
Cnic of Nominee
khurram Shah
Feb 6 1995 12:00AM
Spouse
50
84864864866664
Faisal Shah
Feb 2 1994 12:00AM
Son
50
Medical History
Heart Trouble; Diabetes or Impaired Glucose Tolerance; Sugar, Blood or Protein in Urine; High Blood Pressure; Elevated Blood Cholesterol levels; Elevated Blood Creatinine / Urea Levels; Elevated Blood Liver Enzymes? : No Blood Circulation Disorders; Blood Clotting Disorders (including Stroke / Thrombosis); Chest Pain; Breathing Problem; Cold Sweats, Palpitations; General Weakness, Dyspnea, Apnea, etc.? : No Cancers; Tumors; Tissue / Organ Growth (benign / malignant); Cyst or Mass accumulation? : No Thyroid, Prostate, Lymph-node, Pituitary, Adrenal and / or other Gland(s)? : No Respiratory; Digestive; Genital-Urinary; Hepatic; Endocrine; Muscular-Skeletal; Nervous and / or Auto-Immune System (s)?: No Sexual and Reproductive organs; including Testicles, Uterus (Womb), Cervix, Ovaries, Fallopian-tubes etc.? : No Liver, Lungs, Kidney, Bladder, Stomach, Bowel, Spine, Nerves, Connective tissues, Pancreas, Spleen, Gall Bladder, Brain, Bones, Muscles, Skin, Eyes, Nose or Throat?: No
Blood or Serous Fluids including but not limited to Anemia, Hemophilia, Lymphoma, Leukemia, Myeloma, Thrombocytopenia, Idiopathic Thrombocytopenic Purpura (ITP), Thalassemia, Thrombosis, Sickle Cell Disease, Systemic Lupus Erythematosus (SLE), Any bleeding Disorder etc.?: No Sexual Transmitted Diseases (STD), Human Immunodeficiency Virus (HIV) Infection, Acquired Immune-deficiency Syndrome (AIDS), AIDS-Related Complex (ARC)? : No Hepatitis B / C Infection, Jaundice, Tuberculosis, Polio, Meningitis, Colitis, Cerebral Malaria, Pneumonia, Bronchitis, Asthma, Emphysema, etc.? : No Acute Respiratory Distress Syndrome (ARDS), Panic Attacks, Nervous Breakdown, Suicidal tendencies, Epilepsy, Fainting, Seizers, Fits, Headaches, Convulsions, Dizziness, Blackouts, or any similar type of problem / disorder? : No Injury, Disability, Deformity, Abnormality, Dismemberment, Total / Partial Paralysis (including Hemiplegia / Paraplegia) and / or Loss / Impairment / Disease of Sight, Speech, Hearing, Memory, Touch or any sensory disability? : No Any Congenital, Hereditary, Familial Disease or any Medical / Mental condition or illness / disease not mentioned here above? : No Have you in the last five years visited any doctor, received treatment, had medical checkup, undergone medical tests / examinations, had any type of Surgery, undergone Invasive Procedure, Cardiac Catheterization (Angiography / Angioplasty), Endoscopy, Biopsy, Pap's Smear, Trans-esophageal Echocardiography, Trans-vaginal or Trans-Rectal Ultrasound or any other, Test / Procedure / Treatment? : No Does any Family Member / Blood Relative suffer from or has suffered from any Chronic / Serious infection, Congenital abnormality, Hereditary / Familial Disease, Autoimmune Disease, Diabetes, Heart Disease, Cancer, Thalassemia, Hemophilia, Connective Tissue Disorders, Parkinson's Disease, Multiple Sclerosis, Alzheimer's Disease or any mental, and / or neurological disorders? : No Are you Pregnant? : No Did you ever suffer from Miscarriage / Abortion?: No Do you have or have you ever had any Obstetrical or Gynecological disease/disorder? : No Do you have or have you ever had any chronic / serious disease or medical ailment? : No Do you suffer from, infertility, disease of breasts, disease of reproductive organs (uterus, ovaries, cervix, fallopian-tubes, etc.)? : No Details: