Date of Birth (required)
Name of the Insurance Company Designation
I am enclosing Cash / Demand Draft / Cheque No.______________dated _____________
Drawn on __________________ for Rs. _______________
In favour of “Life Underwriters Guild of India – Subscription A/c.” Payable at Coimbatore.
If payments are made thru’ Outstation cheque: plz. Add Rs.100/- towards Bank charges.
Option 2: Direct Remittance Mode:
Scan copy of cash deposit Challen at _________Branch of Andhra Bank on ____________,