BSNL KERALA EXECUTIVES' & NON EXECUTIVES' HEALTH INSURANCE SCHEME: 2021-2022
by New India Assurance Insurance Company Ltd (Total Amount Claimable for a Family - Rs 5 Lakh only)
Name of BSNL employee *
HR Number *
Date of Birth of Employee *
MM
/
DD
/
YYYY
Age of Employee *
Age Band of Employee *
Option for Top-up
Clear selection
Gender of Employee *
Required
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 *
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
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