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Proposer Details PROPOSER DOB (DD/MM/YYYY) ADDRESS

Insured Members Details Insured Name Insured Gender


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Nominee Details Name Address
CITY STATE

Insured Date of Birth (DD/MM/YYYY) Insured Relationship with Proposer

DOB(dd/mm/yyyy) Relationship with Insured


PINCODEΞΞ PHONE 1 PHONE 2

Insured Height(Cm)ΞΞ Insured Weight(Kg)ΞΞ Insured Occupation


MOBILEΞΞ

Name of illness/injury suffering from or suffered in the past


EMAIL ID Marital Status

Date of first diagnosis (Month & Year) Treatment/medication received/receiving


Educational QualificationΞΞ OccupationΞΞ

Treatment outcome (fully cured/ partially cured/ongoing, etc)


Annual Gross Income in (RS) Policy Type If Floater,Plz Select Number of Persons
Proposed Policy Term