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)
* Required
Name of BSNL employee
*
Your answer
HR Number
*
Your answer
Date of Birth of Employee
*
MM
/
DD
/
YYYY
Age of Employee
*
Your answer
Age Band of Employee
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Choose
Below 20 Yrs
21 to 25 Yrs
26 to 30 Yrs
31 to 35 Yrs
36 to 40 Yrs
41 to 45 Yrs
46 to 50 Yrs
51 to 55 Yrs
56 to 60 Yrs
Option for Top-up
5 Lakh
Nil
Clear selection
Gender of Employee
*
Male
Female
Third Gender
Required
Designation
*
Your answer
Telecom Circle/ State
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Choose
Kerala
Others
For other than kerala Circle
Your answer
Business Area / SSA / District
Trivandrum
Kollam
Pathanamthitta
Alleppey
Kottayam
Ernakulam
Thrissur
Palakkad
Malappuram
Kozhikode
Kannur
Circle Office
Others
BA / SSA / District for other than Kerala Circle
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Residential Address of Employee
*
Your answer
Pincode
*
Your answer
Contact Mobile Number
*
Your answer
Whatsapp Number
*
Your answer
Email ID
*
Your answer
Total number of members to be covered (including self)
*
Your answer
Name of Spouse
Your answer
Date of birth of Spouse
MM
/
DD
/
YYYY
Age of Spouse
Your answer
Gender of Spouse
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Male
Female
Third Gender
Relation with Employee
Your answer
Name of Child 1
Your answer
Age of Child 1
Your answer
Gender of Child 1
Male
Female
Third Gender
Clear selection
Date of Birth of Child 1
MM
/
DD
/
YYYY
Relationship to Employee
Your answer
Name of Child 2
Your answer
Age of Child 2
Your answer
Gender of Child 2
Male
Female
Third Gender
Clear selection
Date of birth of Child 2
MM
/
DD
/
YYYY
Relationship to Employee
Your answer
Name of Child 3
Your answer
Age of Child 3
Your answer
Gender of Child 3
Male
Female
Third Gender
Clear selection
Date of Birth of Child 3
MM
/
DD
/
YYYY
Relationship to Employee
Your answer
Name of Employees' Parents (Primary Member)
Your answer
Date of birth of Employees' Parents (Primary Member)
MM
/
DD
/
YYYY
Age of Employees' Parents (Primary Member)
Your answer
Gender of Employees' Parents (Primary Member)
Male
Female
Third Gender
Clear selection
Relation with Employee
Your answer
Name of Employees' Parents (Dependent Member)
Your answer
Date of birth of Employees' Parents (Dependent Member)
MM
/
DD
/
YYYY
Age Employees' Parents (Dependent Member)
Your answer
Gender of Employees' Parents (Dependent Member)
Male
Female
Third Gender
Clear selection
Relation with Employee
Your answer
Name of Employees' Parents-in-law (Primary Member)
Your answer
Date of birth of Employees' Parents-in-law (Primary Member)
MM
/
DD
/
YYYY
Age of Employees' Parents-in-law (Primary Member)
Your answer
Gender of Employees' Parents-in-law (Primary Member)
Male
Female
Third Gender
Clear selection
Relation with Employee
Your answer
Name of Employees' Parents-in-law (Dependent Member)
Your answer
Date of birth of Employees' Parents-in-law (Dependent Member)
MM
/
DD
/
YYYY
Age of Employees' Parents-in-law (Dependent Member)
Your answer
Gender Employees' Parents-in-law (Dependent Member)
Male
Female
Third Gender
Clear selection
Relation with Employee
Your answer
Declaration
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I confirm that the information given in this form is true, complete and accurate.
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