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Personal Details
Basic Info
Quote Info
Show Premium Info
Quotation Form
Policy Details
Policy Mode
New
Policy Duration
Select
1 Year
2 Year
3 Year
Policy No
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Start Date
End Date
Personal Details
Title
Select
Mr.
Mrs.
Miss.
Dr.
Proposer Name
Proposer Name is required.
Date of Birth
Date of Birth is required.
Gender
Male
Female
Transgender
Mobile
Mobile number is too short.
Mobile number is too long.
Enter a numeric value
Email Id
Email is required.
Invalid email address.
Std No
Phone No
ID Type
Select
PAN No.
Aadhaar Card No.
Driving Licens No.
Voter’s Card No.
Passport No
OTH Other Detail
ID No
ID No is required.
Proposer Occupation
Select
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Annual Income(Rs)
Annual Income is required.
Contact Details
Location
Pin Code
Select Pin
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Address Line 1
Address Line 1 is required.
Address Line 2
Address Line 2 is required.
GST Details
Inward Credit For GST Number?
Yes
No
GST Number
GST Number is required.
Proposal Details
No of Members
Select
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Member Details
Relationship with Proposer
Select
{{t.FamilyCom}}
Member Name
Gender
Male
Female
Transgender
Date of Birth
Occupation
Select
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Sum Insured
Select
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Nominee Name
Relationship with Nominee
Select
{{t.FamilyCom}}
Pre-existing disease
Yes
No
No
Relationship With Proposer
Name
Gender
DOB
Occupation
Sum Insured
Nominee Name
Relationship with nominee
Pre-existing disease
Remove
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In case of the nominee is a minor, Please provide the name of the guardian too.
Yes
No
Please provide the name of the guardian.
If any Hereditary Diseases
Yes
No
Please provide details of ereditary Diseases (if any)/ Family Medical History.
Health Status Details
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Select
Yes
No
If you answerd YES to any of the above question, please provide details below.
Has any Company
a. Declained to issue a policy to you or your proposed family member?
Yes
No
b. Declained to continue your Insurance or proposed family member?
Yes
No
c. Not invited renewal of your or your proposed family family member
Yes
No
d. Imposed any restriction or special conditions.
Yes
No
If so, please give name and address of each company in respect of a,b,c,d above.
Other Company Details
12. Is this Insurance to be additional to any other Critical Illness or Medical Health insurance?
Yes
No
a. Name and adress of Company:
b. Number of persons covered under the Policy:
c. Benefits under the Policy:
d. Sum Insured:
e. Policy Number:
Total Premium to be paid for your complete health insurance is :
(Exclusive of GST)
Summary
Quotation No.
Quotation Date
Proposer Name
Policy Start Date
Policy End Date
Total Sum Insured
Family Composition
Member Summary
No
Name
Sum Insured
Premium
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Premium Summary
Basic Premium: (A)
Loading Details
Occupation Loading:
Total Premium on Loading: (B)
Discount Details: Discount(%)
Discount(%)
Policy Duration Discount:
Total of Discounts: (C)
Net Premium : (A+B-C)
IGST (18%) :
CGST (9%) :
SGST (9%) :
UGST (9%) :
Final Premium :
I have read and understood the Declaration, hereby agree to agreements, terms and conditions mentioned in
Declaration.
Payment.
