BSNL Ex-employees' Health Insurance Scheme.
by New India Assurance Company Ltd (Total Amount Claimable for a Family - Rs 5 Lakh only)
Kindly go through the Policy Conditions before filling the form
Captionless Image
Name of BSNL Ex-employee *
HR Number *
VRS Optee/ Retired *
Date Of Birth of Ex-employee *
MM
/
DD
/
YYYY
Age of Ex-employee *
Age Band of Ex-employee *
Gender of Ex-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 Ex-employee (FULL POSTAL ADDRESS) *
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 Ex-employee
Declaration *
Required
Submit
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