(cICrLombard
uIFALIu ARLE
CPI/lnward Number: 1
BUSINESS SOURCE DETAILS
GoLA Vo
Name of RM(Mandatory RAVI RLVEDL Employee ID : 030262 RMLocation:
Inward Date
Secondary MO Name:
Primary Vertical EM G RETATL Secondary Vertical
Secondary Sub Vertical:
Agancy 1 2.
Primary Sub Vertical: VO
IL Location :LAKHIMPUResG Localion: Additional CST RM Name:
NEFT Details Change (Renewal- GHI): Yes/NO
Type of policy New/Renewal/Rollover/NFE
Previous Policy No:
Moral Hazard No:
IF GHI(NFE)(Ex0sting Product):
PAYOUT DETAILS
Group Administrator Broker Others
Corporate Agent
IL-Co-ins Leader: 1) 100 % Payout/ 2) IL Share payout
BrokeriAgent Intemediary Name: ANOoP NiS HAD
BrokerAgent Antemediary Code : IM-2o93269 Commission %
: Is
POLICY ISSUANCE DETAILS
Name of Insured Papþu Tent &ight House Picy Stat Date
Ms wORKMAN
Product Name CoMPEN SATeNProduct Code
DCI (Reg ID (GHI)
Custome D :lo92 Ssos 66O0D Alternate Policy No:
QMS IDSamadhan ID
FinaVProvisional Product Type :oeNon OTCA PartnerRenewal Notice
Type of Booking
Leader/Follower/ No Co-insurance All Co-insurer details with share%:
Coinsurance Type
(Applicable for Leader &Follower)
URN (Co insurance) Domestic/ Intemational:
RIIward Yes/No RI Inward Type:
RM Name for SPGIBG:
Network Partner (NP): YesNo NP Name:
ENDORSEMENT ISSUANCE DETAILS
Proposal/ Policy No - Cancellation
Name of Insured
Endorsement Number.
Policy Number 40le|38938823/on) oo
Endorsement Effective Date:
Policy Start date
PID (Proposal cancel cases):
23)yl20ns
Custormer ID Refund Type :CDBG/Cheque/Fund TransferiAdjustnent
Endorserment Type
URN (Endorsements)
GSTN Details provided earlier: Yes/No
PAYMENT DETAILS
Cheque/DDICDBGFund Transfer/Adjustment/Debit/Credit card/Net Banking CDBG Ac no.
Mode of payment
Instrument No. & Amount: Date of lnstrument:
Premium Amt: IL Share (Coin_urance)
Bank Name
Underwriter Narme
Total Premium: 712 8/
Yes Select Single Invojce/ Multiple Invoice PID/CCR No:
GST Registered: Yes / NO
INTERMEDIARY DETAILS-Mandatory If Primary Vertical BA &Sub Primary Vertical: BBG & KRG
Source Name BBG Al CRFG CVCE TW PL
BLG ETRG Online COBG SMEAG
CE CPM CSG Jewel Loan KCC
TASC
Tractor Loan RLG SAG/Corp Salary PCG CLB
SLE EC-RBC EC-CBF CE-CPM
Source Name ISec Select Wealth Premier
Source Name KRG Branch Banking SME Others
Channel Name (For I Bank &ISec): BRANCH NON BRANCH (For KRG):
Branch Name:
SOL ID: (For search purpose only)
SP Name: SP Code:
Channel Emp Name: Channel Emp ld:
Cust Ref No: