BSNL KERALA EXECUTIVES' & NON EXECUTIVES' HEALTH INSURANCE SCHEME: 2022-2023
by New India Assurance Insurance Company Ltd
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POLICY CONDITIONS
PAGE 2
POLICY CONDITIONS_MALAYALAM
PAGE 2
Name of BSNL employee *
HR Number *
Date of Birth of Employee *
MM
/
DD
/
YYYY
Age of Employee *
Age Band of Employee *
Gender of Employee *
Required
Designation *
Telecom Circle/ State *
For other than kerala Circle
Residential Address of Employee *
Pincode *
Contact Mobile Number *
Whatsapp Number *
Email ID *
Total number of members to be covered (including self) *
Name of Spouse
Date of birth of Spouse
MM
/
DD
/
YYYY
Age of Spouse
Gender of Spouse
Relation with Employee
Name of Child 1
Age of Child 1
Gender of Child 1
Clear selection
Date of Birth of Child 1
MM
/
DD
/
YYYY
Relationship to Employee
Name of Child 2
Age of Child 2
Gender of Child 2
Clear selection
Date of birth of Child 2
MM
/
DD
/
YYYY
Relationship to Employee
Name of Child 3
Age of Child 3
Gender of Child 3
Clear selection
Date of Birth of Child 3
MM
/
DD
/
YYYY
Relationship to Employee
Name of Employees' Parents (Primary Member)
Date of birth of Employees' Parents (Primary Member)
MM
/
DD
/
YYYY
Age of Employees' Parents (Primary Member)
Gender of Employees' Parents (Primary Member)
Clear selection
Relation with Employee
Name of Employees' Parents (Dependent Member)
Date of birth of Employees' Parents (Dependent Member)
MM
/
DD
/
YYYY
Age Employees' Parents (Dependent Member)
Gender of Employees' Parents (Dependent Member)
Clear selection
Relation with Employee
Name of Employees' Parents-in-law (Primary Member)
Date of birth of Employees' Parents-in-law (Primary Member)
MM
/
DD
/
YYYY
Age of Employees' Parents-in-law (Primary Member)
Gender of Employees' Parents-in-law (Primary Member)
Clear selection
Relation with Employee
Name of Employees' Parents-in-law (Dependent  Member)
Date of birth of Employees' Parents-in-law (Dependent  Member)
MM
/
DD
/
YYYY
Age of Employees' Parents-in-law (Dependent  Member)
Gender Employees' Parents-in-law (Dependent  Member)
Clear selection
Relation with Employee
Declaration *
Required
Submit
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