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name : 
gender : 
Address 1 : 
Address 2 : 
City : 
occupation : 
age/DOB : 
Phone : 
* e-mail : 
 
 
 
what are your preferred mode of investment ?
 
bank
 
stocks
 
mutual funds
 
Other
 
 
 
 
have you invested in insurance plans ?
 
no
 
yes(coverd/amount)
 
 
 
 
which company ?
 
LIC
 
BAJAJ ALLIANZ
 
MAX LIFE
 
Other
 
 
 
 
for waht purpose have you taken insurance policy
 
saving
 
protection
 
tax benifits
 
Other
 
 
 
 
what are your future financial goals ?
 
child education/marriage
 
own house
 
tax benifits
 
Other
 
 
 
 
are you aware about insurance products and its benefits ?
 
yes
 
no
 
 
 
what is your measure area of concern for investment ?
 
safety
 
high returns
 
liquidity
 
Other
 
 
 
 
have you heard about bharti axa insurance ?
 
yes
 
no
 
 
 
if you are given an option to invest in an instrument which gives you 18% interest/whole life earning. would you like to invest ?
 
interested
 
not interested
 
need some time to think
 
Other
 
 
remarks:
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