Personal Accident With Hospitalization Expense

The policy offers Personal Accident compensation cover including reimbursement of Hospitalization expenses incurred due to an accident.

This is not the proposal form for any insurance product. This form is using to collect data from our tie-up Financiers and customers for further proceedings and or to get Quotation. This is not a public page.

    Name of the Insured

    Gender

    Address

    Date of Birth: (18 to 80 Year)

    Mobile Number

    Occupation of the Insured

    Any Physical Defects ?

    If Any Physical Defects, Details

    Sum Insured for Personal accident (Accident death Cover)

    Sum Insured for hospital expenses due to road accident

    Sum Insured for hospital expenses due to accident in course of employment extension

    Sum Insured for hospital expenses for any other accident

    Policy Duration

    Nominee

    Relationship with the Nominee

    Submitted By


    Insurance is the subject matter of solicitation