QUESTIONNAIRE
MAX NEW YORK LIFE INSURANCE COMPANY LIMITED 12th Floor, DLF Squ r!, " # r $% M r&, DLF C't( Ph )! II, *ur& o$+ 122,,2 FINANCIAL QUESTIONNARE -P!r)o$ l Co.!r)/ Pro0o) l $o1 2 L'3! to 4! I$)ur!%2 SECTION A 1 Pl! )! )t t! (our o##u0 t'o$ 2 Ar! (ou -t'#5 o$!/ a) Employed b) Self employed c) Share holding director (%of share holding) d) In partnership '$)ur!r) I$)ur!r) Su8 A))ur!% R! )o$ 3or Co.!r T(0!9T!r8 o3 Pol'#( yes ( ) , no ( ) yes ( ) , no ( ) yes ( ) , no ( ) yes ( ) , no ( )
6 Pl! )! &'.! %!t 'l) o3 $( #urr!$t 0ol'#'!) th t r! 7'th oth!r l'3!
Pl! )! &'.! %!t 'l) o3 E;')t'$& Pol'#'!) '$ 3or#! 3or L'3! or Su8 A))ur!% R! )o$ 3or Co.!r T(0!9T!r8 o3 Pol'#(
T(0!9T!r8 o3 Pol'#( D') 4'l't( <!$!3't) I$)ur!r)
Pl! )! )t t! E r$!% I$#o8! '$ th! l )t t ; (! r -3or )!l3 !80lo(!% ) ))!))!% 3or '$#o8! t ; 3t!r
0!r)o$), )t t! 0!r)o$ l ! r$'$&)
%!%u#t'o$ o3 llo7 4l! 4u)'$!)) !;0!$)!)1/
> Pl! )! !)t'8 t! th! . lu! o3 (our P!r)o$ l A))!t) $% L' 4'l't'!)1 A))!t) Property Investments Un !oted e !ities "thers(please specify) #otal ?Nu84!r $% A&! o3 D!0!$%!$t) #otal L' 4'l't'!) Mortgages Loans "thers(please specify)
@ Wh t ') th! r! )o$ 3or 00l('$& 3or th') 0ol'#( (Please tic$ the appropriate one) a) %amily Protection b) Personal Protection d) "thers (please specify) () () ()
c) Private &esidential Loan 'over ( )
SECTION < Pl! )! )t t!2 () &eason for Loan )) *ame of Lender +) *ame(S) of ,orro-er(S) .) /mo!nt of Loan 0) #erm of Loan 1) Interest &ate 2) &epayment method (e3g3 interest only, capital and interest) I hereby declare and agree that the above partic!lars and ans-ers are complete and tr!e, that I have not held bac$ any relevant facts or details, and that the ans-ers to !estionnaire -ill form part of the application for the desired ins!rance on my life3 S'&$ tur! o3 L'3! to 4! I$)ur!% QUESTIONNAIRE OF A*ENTS DATE2
Q1 1 Mot'. t'$& 3 #tor 7h'#h I$)ur $#!A Money &ecognition
33!#t)
&!$t o3 M ; N!7 Yor5 L'3!
/ssertion -ith an organi4ation Infl!enced by others s!ccess 5ad free time Q1 2 Wh t 3 #tor )houl% 4! #o$)'%!r!% 7h'l! #o88u$'# t'$& 7'th 0ot!$t' l #u)to8!r)A Patience 'omm!nication &elation b!ilding Persistence 5ard-or$ing Q1 6 Wh t 0!r#!$t &! o3 #u)to8!r) r! ) t')3'!% 7'th th! )!r.'#! o3 M ; N!7 Yor5 L'3! I$)ur $#!A 'omfortable *ote comfortable Q1 : Wh t 0!r#!$t &! o3 #u)to8!r) r! '$3lu!$#!% 4( th! &!$tA Infl!enced *ot infl!enced did not attend Q1 = Wh t 0!r#!$t &! o3 #u)to8!r) r! ) t')3'!% 4( th! tr '$'$& 0ro&r 88! o3 th! &!$tA Satisfied
Unsatisfied
<I<LIO*RAPBY 11 <oo5) Mishra3M3* ,Modern 'oncept of Ins!rance, 6ear (777 I'89), I'8++ Ins!rance Instit!te "f India,6ear )999 :othari '3& , &esarch Methodolgy,6ear )997 ;!pta3S3L, Mar$eting Service,6ear )99< Life Ins!rance =ol!me ( 8 I'%/I Press,6ear )99< 21 N!7)0 0!r) $% 8 & C'$!)2 Ins!rance 'hronical by I'%/I, Edn3 >!ne8)99< Economic times, Edn3 May8)99< #imes of India, Edn3 )+, >!ne8)99< 61 W!4)'t!)
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