Health Proposal
Policy
*
Select Option
Fresh
Port
Name of Proposer
*
Contact Number
*
Email ID
*
DOB
*
Gender
*
Select Gender
Male
Female
Address
*
Height(Feet)
*
Height(Inches)
*
Weight
*
Marital Status
*
Select Marital Status
Single
Married
Married having children
Spouse
Name of Spouse
*
DOB
*
Gender
*
Select Gender
Male
Female
Height(Feet)
*
Height(Inches)
*
Weight
*
Kid
Name of Kid
*
Gender
*
Select Gender
Male
Female
DOB
*
Height(Feet)
*
Height(Inches)
*
Weight
*
Check for 2nd Kid
Name of Kid
*
Gender
*
Select Gender
Male
Female
DOB
*
Height(Feet)
*
Height(Inches)
*
Weight
*
Check for 3rd Kid
Name of Kid
*
Gender
*
Select Gender
Male
Female
DOB
*
Height(Feet)
*
Height(Inches)
*
Weight
*
Nominee
Name of Nominee
*
Gender
*
Select Gender
Male
Female
DOB
*
Relationship with proposer
*
Sum Assured
*
Select Option
5 lacs
10 lacs
15 lacs
20 lacs
25 lacs
50 lacs
Year of Cover
*
Select Option
1 year
2 year
3 year
PED
*
Select Option
Yes
No
PED Options
*
Select Option
Hypertension
Diabetes
Any Heart Related or Circulatory Conditions Disorders
Kidney Failure stone Dialysis or any other kidney urinary tract or prostate disease
Arthritis spondylosis joint repalcement or any other disorder of joint ligaments
Tuberculosis asthma bronchitis or any other lung respiratory disease,
Liver disease or any other Gastro Intestinal or Gallbladder Disease
Cancer or Tumor of any kind
Stroke Epilepsy paralysis or any other brain nervous system diasease
Other PED
PED
*
Have you Tested Covid-19 positive?
*
Select Option
Yes
No
If Yes, Please select the option
*
Select Option
In last 45 days
Covid-19 Hospitalisation
Covid-19 Home Isolation
Any major and minor surgery in past?
*
Select Option
Yes
No