MEDICAL INSURANCE WAIVER/CONSENT
Email address *
All students enrolled at FIIB have to submit proof of their Medical Insurance. Alternately, FIIB offers Medical Insurance under its group policy for interested students. Indicate your preference below for opting-out or opting-in to the FIIB Group Medical Insurance.
I would like to:
Part A
I want to avail for FIIB’s group medical policy.
Policy Coverage - INR 50,000/- annually for 2 years
Premium for Two years - INR 2,000/-

The coverages under FIIB Group Policy are valid for both years of the students’ enrolment at FIIB.

My details for the group medical policy are as mentioned below : Name
Your answer
Gender
Date of Birth
MM
/
DD
/
YYYY
Address
Your answer
Mobile Number
Your answer
Email ID
Your answer
Part B
I undertake that I have a Medical Insurance Policy in my name with following details:
Policy Number
Your answer
Name of the Company
Your answer
Date of Issue
MM
/
DD
/
YYYY
Date of Expiration
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Fortune Institute of International Business. Report Abuse - Terms of Service