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IND.HEALTH PROPOSAL
↘️ FILL ALL COLUMN WITH PROPER ANSWER,PLEASE DO NOT LEAVE BLANK FIELD, IF NOT REQUIRED ANY FIELD JUST LEAVE IT ↙️
Full Name✳️
Date of Brith✳️
Gender✳️
FEMALE
MALE
Married Status֍
MARRIED
UNMARRIED
Height✳️
Weight✳️
Pan No
Aadhar No✳️
Mobile No✳️
Email ID✳️
Occuation✳️
OTHERS
SALARIED
SELF EMPLOYED
Daily Cash (Option)
—Please choose an option—
NO
YES-DAILY 1000
YES-DAILY 1500
YES-DAILY 500
Address✳️
City✳️
State✳️
Pincode✳️
Nominee Name✳️
Date Of Birth✳️
Relationship✳️
—Please choose an option—
DAUGHTER
FATHER
MOTHER
SON
SPOUSE
TPA
NO
YES
YOUR AGE GROUP✳️
i. Platinum Plan Age- 0 to 35
ii. Gold Plan Age- 36 to 60
iii.Senior Plan Age- 61 to 65
Sum Insured✳️
—Please choose an option—
Gold Sum Insured 10 Lakhs,
Gold Sum Insured 2 Lakhs,
Gold Sum Insured 3 Lakhs,
Gold Sum Insured 5 Lakhs,
Gold Sum Insured 8 Lakhs,
Platinum Sum Insured 10 Lakhs,
Platinum Sum Insured 15 Lakhs,
Platinum Sum Insured 2 Lakhs,
Platinum Sum Insured 20 Lakhs,
Platinum Sum Insured 3 Lakhs,
Platinum Sum Insured 5 Lakhs,
Platinum Sum Insured 8 Lakhs,
Senior Sum Insured 2 Lakhs,
Senior Sum Insured 3 Lakhs,
Senior Sum Insured 5 Lakhs,
Start E.11/03/2024✳️
End E.10/03/2025✳️
👬🏽IF REQUIRED COVER FOR FAMILY MEMEBRS,PLEASE FILL, ONLY REQUIRED COLUMNS, IF NOT, JUST LEAVE IT, AS IT IS FORM👩🏻🤝👨🏼
Details⏬⏬⏬⏩⏩⏩
𝗙𝘂𝗹𝗹 𝗡𝗮𝗺𝗲 ⏩⏩⏩
𝐃𝐚𝐭𝐞 𝐨𝐟 𝐁𝐢𝐫𝐭𝐡 ⏩⏩⏩
𝐆𝐞𝐧𝐝𝐞𝐫⏩⏩⏩⏩⏩⏩
𝐌𝐚𝐫𝐢𝐭𝐚𝐥 𝐒𝐭𝐚𝐭𝐮𝐬⏩⏩⏩
𝐎𝐜𝐜𝐮𝐩𝐚𝐭𝐢𝐨𝐧⏩⏩⏩
𝐀𝐚𝐝𝐡𝐚𝐫 𝐍𝐨⏩⏩⏩
𝐒𝐮𝐦 𝐈𝐧𝐬𝐮𝐫𝐞𝐝⏩⏩⏩
𝐇𝐞𝐢𝐠𝐡𝐭(cm)⏩⏩⏩
𝐖𝐞𝐢𝐠𝐡𝐭(kg)⏩⏩⏩
𝐑𝐞𝐥𝐚𝐭𝐢𝐨𝐧𝐬𝐡𝐢𝐩/W.Pro
𝐃𝐞𝐩𝐞𝐧𝐝𝐞𝐧𝐭⏩⏩⏩
2nd Person
—Please choose an option—
FEMALE
MALE
N.A
MARRIED
N.A
UNMARRIED
—Please choose an option—
N.A
OTHERS
SALARIED
SELF EMPLOYED
10 Lakhs-Gold Plan
10 Lakhs-Platinum
15 Lakhs-Platinum
2 Lakhs-Gold Plan
2 Lakhs-Platinum
2 Lakhs-Senior Plan
20 Lakhs-Platinum
3 Lakhs-Gold Plan
3 Lakhs-Platinum
3 Lakhs-Senior Plan
5 Lakhs-Gold Plan
5 Lakhs-Platinum
5 Lakhs-Senior Plan
8 Lakhs-Gold Plan
8 Lakhs-Platinum
N.A
—Please choose an option—
DAUGHTER
FATHER
MOTHER
N.A
OTHERS
SELF
SON
SPOUSE
—Please choose an option—
N.A
NO
YES
3rd Person
—Please choose an option—
FEMALE
MALE
N.A
MARRIED
N.A
UNMARRIED
—Please choose an option—
N.A
OTHERS
SALARIED
SELF EMPLOYED
10 Lakhs-Gold Plan
10 Lakhs-Platinum
15 Lakhs-Platinum
2 Lakhs-Gold Plan
2 Lakhs-Platinum
2 Lakhs-Senior Plan
20 Lakhs-Platinum
3 Lakhs-Gold Plan
3 Lakhs-Platinum
3 Lakhs-Senior Plan
5 Lakhs-Gold Plan
5 Lakhs-Platinum
5 Lakhs-Senior Plan
8 Lakhs-Gold Plan
8 Lakhs-Platinum
N.A
—Please choose an option—
DAUGHTER
FATHER
MOTHER
N.A
OTHERS
SELF
SON
SPOUSE
—Please choose an option—
N.A
NO
YES
4th Person
—Please choose an option—
FEMALE
MALE
N.A
MARRIED
N.A
UNMARRIED
—Please choose an option—
N.A
OTHERS
SALARIED
SELF EMPLOYED
10 Lakhs-Gold Plan
10 Lakhs-Platinum
15 Lakhs-Platinum
2 Lakhs-Gold Plan
2 Lakhs-Platinum
2 Lakhs-Senior Plan
20 Lakhs-Platinum
3 Lakhs-Gold Plan
3 Lakhs-Platinum
3 Lakhs-Senior Plan
5 Lakhs-Gold Plan
5 Lakhs-Platinum
5 Lakhs-Senior Plan
8 Lakhs-Gold Plan
8 Lakhs-Platinum
N.A
—Please choose an option—
DAUGHTER
FATHER
MOTHER
N.A
OTHERS
SELF
SON
SPOUSE
—Please choose an option—
N.A
NO
YES
5th Person
—Please choose an option—
FEMALE
MALE
N.A
MARRIED
N.A
UNMARRIED
—Please choose an option—
N.A
OTHERS
SALARIED
SELF EMPLOYED
10 Lakhs-Gold Plan
10 Lakhs-Platinum
15 Lakhs-Platinum
2 Lakhs-Gold Plan
2 Lakhs-Platinum
2 Lakhs-Senior Plan
20 Lakhs-Platinum
3 Lakhs-Gold Plan
3 Lakhs-Platinum
3 Lakhs-Senior Plan
5 Lakhs-Gold Plan
5 Lakhs-Platinum
5 Lakhs-Senior Plan
8 Lakhs-Gold Plan
8 Lakhs-Platinum
N.A
—Please choose an option—
DAUGHTER
FATHER
MOTHER
N.A
OTHERS
SELF
SON
SPOUSE
—Please choose an option—
N.A
NO
YES
6th Person
—Please choose an option—
FEMALE
MALE
N.A
MARRIED
N.A
UNMARRIED
—Please choose an option—
N.A
OTHERS
SALARIED
SELF EMPLOYED
10 Lakhs-Gold Plan
10 Lakhs-Platinum
15 Lakhs-Platinum
2 Lakhs-Gold Plan
2 Lakhs-Platinum
2 Lakhs-Senior Plan
20 Lakhs-Platinum
3 Lakhs-Gold Plan
3 Lakhs-Platinum
3 Lakhs-Senior Plan
5 Lakhs-Gold Plan
5 Lakhs-Platinum
5 Lakhs-Senior Plan
8 Lakhs-Gold Plan
8 Lakhs-Platinum
N.A
—Please choose an option—
DAUGHTER
FATHER
MOTHER
N.A
OTHERS
SELF
SON
SPOUSE
—Please choose an option—
N.A
NO
YES
📑PLEASE FILL YOUR OLD HEALTH POLICY DETAILS IN THE BELOW COLUMN. IF NOT AVAILABLE, JUST LEAVE IT, AS IT IS FORM🧾
COMPANY NAME
POLICY NO
POLICYT YPE
BESE POLICY
N.A
TOP UP POLICY
POLICY EXPIRY
SUM INSURED
Porting/Migrating
Migrating
N.A
Porting
🚭ANY PERSON WHO IS PROPOSED FOR INSURANCE CONSUME BELOW ITEMS. PLS FILL, IF NOT JUST LEAVE IT, AS IT IS FORM.🚭
1st Person
Alcohol
Tobacco
Illegal Drugs
2nd Person
Alcohol
Tobacco
Illegal Drugs
3rd Person
Alcohol
Tobacco
Illegal Drugs
4th Person
Alcohol
Tobacco
Illegal Drugs
5th Person
Alcohol
Tobacco
Illegal Drugs
6th Person
Alcohol
Tobacco
Illegal Drugs
IF THE ABOVE COLUMN 'YES' ANY ONE OF THE FIELD ,THEN GIVE QUANTITY CONSUMED PER WEEK DETAILS IN THE RESPECTIVE FIELD AND PLEASE MENTION THE CONSUMED PERSON NAME. IF THE ABOVE ALL COLUMN 'NO' JUST LEAVE IT, AS IT IS FORM
Alcohol
Tobacco
Illegal Drugs
AILMENT OR ACCIDENT , GIVE DETAILS WITH PERSON NAME,OR JUST LEAVE IT
Health Issue
PLEASE UPLOAD PROPOSER PAN & SIGN AND HIS PHOTO ALONG WITH MEMBERS PHOTOS ALSO ALLMEMBERS AADHAR COPY
Proposer Photo✳️👇🏻
Propop. Aadhar✳️👇🏻
Person 2️⃣ Photo👇🏻
Person 2️⃣ Aadhar👇🏻
Person 3️⃣ Photo👇🏻
Person 3️⃣ Aadhar👇🏻
Person 4️⃣ Photo👇🏻
Person 4️⃣ Aadhar👇🏻
Person 5️⃣ Photo👇🏻
Person 5️⃣ Aadhar👇🏻
Person 6️⃣ Photo👇🏻
Person 6️⃣ Aadhar 👇🏻
Proposer Sign✳️✍🏻
Proposer Pan
Proposal Date✳️👉🏻
Proposal Place✳️👉🏻
BEFORE SUBMIT THE FORM, NOTE 👉🏻 ✳️ 👈🏻 MARKED FIELD INPUT AND UPLOAD ARE MUST BE DONE... 👉🏻👉🏻.