Анкета застрахованного лица (Форма АДВ-1)

Анкета застрахованного лица

Заполняется застрахованным лицом печатными буквами.

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│ С Е Р Г Е Е В │

│Фамилия ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ А Л Е К С А Н Д Р │

│Имя ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ А Н Д Р Е Е В И Ч │

│Отчество ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ М │

│Пол ._. (м/ж) │

│ 1 0 М А Я 1 9 5 0 │

│Дата рождения "._._." ._._._._._._._._._ ._._._._. года │

│Место рождения: │

│ У С Т Ь - Н Е Р А │

│ город (село, дер., ...) ._._._._._._._._._._._._._._._._._._._._._. │

│ О Й М Я К О Н С К И Й │

│ район ._._._._._._._._._._._._._._._._._._._._._. │

│ Я К У Т С К А Я А С С Р │

│ область (край, респ., ...) ._._._._._._._._._._._._._._._._._._._._._. │

│ страна ._._._._._._._._._._._._._._._._._._._._._. │

│ Р О С С И Я │

│Гражданство ._._._._._._._._._._._._._._._._._._._._._. │

│Адрес постоянного места жительства │

│ 1 4 4 0 0 7 М О С К О В С К А Я О Б Л , │

│Адрес индекс ._._._._._._. адрес ._._._._._._._._._._._._._._._. │

│ Э Л Е К Т Р О С Т А Л Ь Г , М И Р А У Л , │

│регистрации ._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ Д 2 0 , К В 1 2 │

│ ._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│Адрес места индекс ._._._._._._ адрес ._._._._._._._._._._._._._. │

│жительства ._._._._._._._._._._._._._._._._._._._._._._._._. │

│фактический ._._._._._._._._._._._._._._._._._._._._._._._._. │

│ (заполнять при отличии от адреса регистрации) │

│ 8 - 9 8 5 - 1 1 1 - 1 3 - 1 2 │

│Телефоны ._._._._._._._._._._._._._._._._._._._._. │

│ (домашний и/или рабочий) │

│Документ, удостоверяющий личность │

│ П А С П О Р Т Р О С С И И │

│Вид документа ._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ (указать название документа: паспорт, удостоверение │

│ личности и другие документы, удостоверяющие личность) │

│ 3 3 - 9 0 7 3 5 2 4 7 │

│Серия, номер ._._._._._._._. ._._._._._. │

│ 2 0 И Ю Н Я 2 0 0 1 │

│Дата выдачи "._._." ._._._._._._._. ._._. года │

│ Г О М О В Д Г О Р И С П О Л К О М А Г Э Л │

│Кем выдан ._._._._._._._._._._._._._._._._._._._._._._._._. │

│ Е К Т Р О С Т А Л Ь М О С К О В С К О Й О Б Л │

│ ._._._._._._._._._._._._._._._._._._._._._._._._._. │

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Дата заполнения Личная подпись

0 2 Ф Е В Р А Л Я 2 0 0 2 СЕРГЕЕВ

"._._." ._._._._._._._._. ._._._._. года застрахованного лица -------