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About

Proposer Form Family

First Name

Last Name

Address

Mobile No

Email

Health Insurer

Motor Insurer

1.Health Policy No & Year

1.Motor Policy No & Year

2.Health Policy No & Year

2.Motor Policy No & Year

3.Health Policy No & Year

3.Motor Policy No & Year

Member 1

Date Of Birth

Height and weight

Pan Card

Aadhar No

Policy No

1

2

3

Member 2

Date Of Birth

Height and weight

Pan Card

Aadhar No

Policy No

1

2

3

Member 3

Date Of Birth

Height and weight

Pan Card

Aadhar No

Policy No

1

2

3

Member 4

Date Of Birth

Height and weight

Pan Card

Aadhar No

Policy No

1

2

3

Member 5

Date Of Birth

Height and weight

Pan Card

Aadhar No

Policy No

1

2

3

Member 6

Date Of Birth

Height and weight

Pan Card

Aadhar No

Policy No

1

2

3

Member 7

Date Of Birth

Height and weight

Pan Card

Aadhar No

Policy No

1

2

3

Member 8

Date Of Birth

Height and weight

Pan Card

Aadhar No

Policy No

1

2

3

Member 9

Date Of Birth

Height and weight

Pan Card

Aadhar No

Policy No

1

2

3

Any Health Claim?

Yes

No

Health Policy No

1

2

3

Any Motor Claim?

Yes

No

Motor Policy No

1

2

3

Hospital Name

Date Of Admit

Date Of Discharge

Reason

Amount

Cashless/Reimbursement

Hospital Name

Date Of Admit

Date Of Discharge

Reason

Amount

Cashless/Reimbursement

Hospital Name

Date Of Admit

Date Of Discharge

Reason

Amount

Cashless/Reimbursement

Any Other Information?

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