Digit Illness Group Insurance
Objective of this form is to record the basic details for enrollment, as required by our insurance partner. Some field are optional but if they are provided, application process becomes easier. In any insurance product the information provided in the form, needs to be filled and spelled accurately, to avoid policy or claim rejection.

This is an indemnity product, covering your actual eligible hospitalization expenses incurred due to Corona virus disease (COVID-19).
Name of your Agency or Riya ID or Riya ICUST number or Employee Code and GST No. (If Applicable) *
Your correct Identification and email will help us pass benefits to you. If applying for your own self, provide your own name.Kindly provide the GST Number if you wish to avail GST benefits after the name.
Customer's City *
Customer's Full Name? (First Name/Middle/Last) *
Customer's Contact Number? (10 Digit ) *
Correct contact number will help insuring company, update them of - issuing and/or claim status 😊
Customer's E-mail Id? *
Correctly spelled email address will help to provide insurance copies and claim support awareness 😊
Select the Customer's Location *
Choose the State carefully, the query is handled by an external agency and will be re-directed to them.
Sum Insured? *
If the customer is undecided, they will have the option to change it, when our experts call and explain the plan.
Looking for Insurance ? *
My Self
My Self + Spouse
My Self + Spouse + Child
My Self + Spouse + 2 Children
Introduce to Family
Family Size ?
Proposers/Applicants Date of Birth ? *
MM
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DD
/
YYYY
Declaration and fine print *
I/Customer am eligible for enrolling in this policy, and that I/Customer have not traveled outside of India in last 30 days nor suffering from disease of diabetes/ heart/ lungs/ kidney/ liver/ cancer, any condition that needs ongoing treatment. I agree to the terms & conditions mentioned under this policy and have read the overview of the policy coverage at https://cutt.ly/RiyaCovid-19Plan
Required
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