Application form for eIA creation

Account Category **		Account Type **

Applicant Details
Bank Details
Authorised Representative Details

Applicant Details

Permanent Address		Correspondence Address
User Id **
PAN / UID
Name	**	Gender **	Male : Female : Other :
Father's / Husband's Name		Date Of Birth *	(DD-MM-YYYY)
Residential Address (Please note : Only the address present with the UIDAI will be captured in the NIR system.)
		Same as Permanent ? Yes No
Address Line 1 *		Address Line 1 *
Address Line 2		Address Line 2
Address Line 3		Address Line 3
Landmark		Landmark
City *		City *
Country *		Country *
State/Union Territory *		State/Union Territory *
Pincode *		Pincode *
Contact Details
Email Id **		Mobile No. **
Telephone No.		FAX No.
Id Proof *
Date Of Birth Proof *
Permanent Address Proof *
Correspondence Address Proof *

Bank Details

Branch Details
Account Type *
Account Number *
Bank Name *
Branch Name *		MICR Code
City *		IFSC Code
Cancelled cheque submitted by Applicant

Authorised Representative Details

Authorised Representative is a Person appointed by an e-Insurance Account holder who can access the e-Insurance Account in the event of the e-Insurance Account holder's demise or in his/her incapacity to access the e-Insurance Account.

Address
PAN / UID
Name	*	Gender *	Male : Female : Other :
Name	*	Date Of Birth *	(DD-MM-YYYY)
Same as Applicant Permanent Address ? Same as Applicant Correspondence Address ? None
Same as Applicant Residential Address ? No
Address Line 1 *		Address Line 2
Address Line 3		Landmark
City *		Country *
State/Union Territory *		Pincode *
Contact Details
Email Id *		Mobile No. *
Telephone No.
Relationship with Applicant *
Do you want to send the Communication to Authorized Representative * Yes No

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(Do not enter space between characters)

Note:

Fields marked as * and ** are mandatory for complete submit.
Fields marked as ** are mandatory for partial submit.
Fields marked as ** indicates that either the PAN number or the UID is compulsory to partially submit/submit the form.