STATE LIFE INSURANCE CORPORATION OF PAKISTAN

Group & Pensions Division

Name of the Applicant	Enter applicant name
Father's / Husband's Name	Enter father's or husband's name
Date of Birth	Enter date of birth
CNIC No.	Enter CNIC number
Particulars of Passport	Enter passport details
Postal Address in Pakistan	Enter address
Amount of Insurance	Rs 300.000 (Rupees Three Hundred Thousand only)
Period of Insurance	Two Years
Date of Commecemant/Renewal of Insurance
Amount of Premium Paid	Rs 650/- (Six Hundred and Fifty only)
Detail of Previous Insurance Certificate	Reg No. Date:

I hereby declare that the particulars given in the application form are true and correct. In case of any misstatement, the State Life Bureau shall have the right to cancel the certificate.

Witness Name

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Signature of Applicant

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Date

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