Online Pure Term Life Product

Personal Information

Health

Summary

Disclaimer: This policy is exclusively available to Sri Lankan nationals.

All fields are mandatory

Name in Full

Email Address

Mobile Number

Gender

Date of Birth

Age

NIC Number

Postal Address

Occupation

Monthly Income

Payment Frequency

Coverage Period (Years)

Contribution Period (Years)

Life Cover

Nominee should be an adult and an immediate family member.

Name in Full

Relationship

Date of Birth

NIC Number

Call / Whatsapp Number

Number of influencers per day

Location restrictions (if any)

Contact person Full Name

Email address

Contact Number

Special instructions (if any)