Family First Financial Services – Insurance Planning Form

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Personal Information

Basic identification & contact details

Full Name *

Date of Birth *

Gender *

Marital Status

No. of Dependants

Do You Consume Tobacco / Smoke? * — affects premium calculation

NoNon-Smoker / Non-Tobacco

Yes – SmokerCigarette / Bidi

Yes – TobaccoGutka / Pan / Chewing

Highest Education Qualification

Post GraduateMBA / M.Com / M.Sc etc.

GraduateB.Com / B.Sc / B.E etc.

Diploma / ITI

12th PassHSC / Intermediate

10th PassSSC / Matriculation

Below 10th

Mobile Number *

Email Address *

City & State / Country of Residence *

PIN Code (Indian PIN / Postal Code)

Residential Status *

Resident Indian

NRINon-Resident Indian

OCI / PIO

Family Financial Dependency

No Dependants

Spouse Only

Spouse + Children

Parents Dependent

Joint Family Responsibility

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Financial Profile

Calibrates premium bands & tax-alpha strategy

Profession / Occupation *

Please specify your profession

Annual Income (Approximate) *

Annual Premium Willingness * Key Filter

Existing Life Insurance Cover Amount (if any)

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Plan You Want to Buy

Helps us prepare the right illustration before your call

Which Plan Are You Interested In? * (select all that apply)

Term Life InsurancePure protection cover

TULIPTax-alpha ULIP structure

ULIPUnit Linked Insurance Plan

Health PlanMediclaim / Critical Illness

Traditional / Endowment

Annuity / Pension

📜 Traditional / Endowment Plan Details

Help us structure the right guaranteed or par plan for your goals

Which Type of Plan Are You Looking For? *

100% Guaranteed Return PlanFixed, assured maturity — no market risk

Bonus / Par PlanParticipating plan with declared bonuses

Annual Premium Amount *

Premium Payment Frequency

Premium Payment Term *

Policy Term *

Get Money As * — how you want maturity / returns

LumpsumFull maturity amount at end

Income – Short TermFixed payouts for limited years

Income – Long TermExtended regular income payout

Immediate IncomePayouts start right away

Income for LifetimeGuaranteed payouts till death

Do You Want Early Income? — income starts during premium payment period itself

Yes – Early IncomePayouts start before policy matures

No – Maturity / End Payout Only

📈 ULIP Plan Details

Unit Linked Insurance Plan — market-linked wealth creation with life cover

Annual Investment Amount *

Payment Frequency

Invest / Pay Premium For * — premium paying term

Withdraw / Maturity After — total policy term

Preferred Fund / Return Type *

Equity / Growth FundHigh risk, high return (market linked)

Balanced / ModerateMix of equity & debt funds

Debt / ConservativeLower risk, stable returns

Advise MeBased on my risk profile

Life Cover Expectation in ULIP

Minimum (10x)Maximise investment value

Higher CoverMore life protection needed

Advise Me

Specific Plan Name (if any)

Preferred Company

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Planning Objectives

Identifies which tax-alpha or protection strategy fits

Primary Financial Goal *

Tax-Free Wealth AccumulationULIP / TULIP with post-tax IRR optimization

Retirement / Pension IncomeGuaranteed annuity, NPS, ULIP pension

Estate Planning & Legacy TransferHUF structuring, FEMA-compliant NRI trusts

High-Cover Term ProtectionPure risk cover for family security

Child Education / Marriage Corpus

Keyman / Business InsuranceCorporate-driven tax deduction strategy

Why Are You Considering Insurance Now? (select all that apply)

Tax Planning

Family Protection

Investment / Wealth Creation

Retirement Planning

Policy Review

Referred by Someone

Investment Horizon *

3–5 Years

7–10 Years

15–25 Years

Risk Appetite

ConservativeGuaranteed returns

ModerateBalanced equity-debt

AggressiveEquity / ULIP heavy

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NRI / Tax Compliance

FEMA, DTAA & foreign income structuring

Country of Residence (if NRI)

NRI Since (Year)

NRE / NRO Account in India?

DTAA Country (if applicable)

Please specify DTAA country

Does Indian Income Attract TDS / Advance Tax?

Yes

No

Not Applicable

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Health & Insurability

Pre-assesses underwriting & premium loading risk

Height — select unit

cm feet / inches

Weight (kg)

Pre-existing Medical Conditions?

Diabetes / Thyroid

Cardiac / BP

None / Healthy

Other (mention below)

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Consultation & Purchase Intent

Helps us prioritise your follow-up

Preferred Consultation Mode *

Preferred Consultation Date

Preferred Time Slot

Are You Planning to Purchase Insurance Within… * 🔥 Hot Lead Indicator

ImmediatelyWithin 1 month

Within 3 Months

Within 6 Months

Just ExploringNo immediate plan

How Did You Hear About Us?

Client Referral

LinkedIn

WhatsApp / Telegram

YouTube

Other

Specific Query / What to Address in the Consultation?

Insurance Planning & Policy
Review Qualification Form

Thank You!

Insurance Planning & PolicyReview Qualification Form

Thank You!

Insurance Planning & Policy
Review Qualification Form