All Kerala BSNL Employees' Health Insurance Scheme (an initiative of Unions and Associations of BSNL Kerala Circle)
by United Insurance Company Ltd (Total Amount Claimable for a Family - Rs 5 Lakh only)
Kindly go through the Policy Conditions before filling the form
Name of BSNL Employee *
HR Number *
Employee / VRS optee / Retired *
Date of Birth of Employee *
MM
/
DD
/
YYYY
Age of the Employee *
Age Band of the Employee *
Sex of the Employee *
Designation *
Telecom Circle / State *
for other than Kerala Circle
Business Area / SSA / District *
BA/SSA/District for other than Kerala Circle
Residential Address of Employee *
Pincode *
Contact Mobile Number *
Email ID *
Total number of members to be covered (including self) *
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