All Kerala BSNL Employees' Health Insurance Scheme (an initiative of all Unions and Associations of BSNL Kerala Circle)
by United Insurance Company Ltd (Total Amount Claimable for a Family - Rs 5 Lakh only)
Email address *
Kindly go through the Policy Conditions before filling the form
Captionless Image
Name of BSNL Employee * *
Your answer
HR Number * *
Your answer
Employee / VRS optee / Retired *
Column 1
BSNL Employee
VRS Optee
Retried and age < 60
Retried and age > 60
Date of Birth of Employee * *
MM
/
DD
/
YYYY
Age of the Employee * *
Your answer
Age Band of the Employee * *
Required
Sex of the Employee * *
Designation * *
Your answer
Telecom Circle / State * *
for other than Kerala Circle *
Your answer
Business Area / SSA / District * *
THIRUVANANTHAPURAM
KOLLAM
PATHANAMTHITTA
ALAPPUZHA
KOTTAYYAM
IDUKKI
ERNAKULAM
THRISSUR
PALAKKAD
MALAPPURAM
KOZHIKODE
WAYANADU
KANNUR
Circle Office
Others
Row 1
BA/SSA/District for other than Kerala Circle *
Your answer
Residential Address of Employee * *
Your answer
Pincode * *
Your answer
Contact Mobile Number * *
Your answer
Total number of members to be covered (including self) *
Your answer
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