Policy Details
Line of Business
Health
Type of Business
New Business
Emp/LG Code
*
Product Name
*
--Select--
Target Date
SP Code
Bank Customer ID (CIF No)
*
Corporate relationship No.
*
Customer Type
*
--Select--
RBG Asset Customer
RBG Liability Customer
KGC Proposal Number
*
Branch Code
HDFC BDR Code
Client ID
*
Saving Account Number
*
HDFC SM code
Customer ID
*
Customer Information
Title
Mr
Mrs
Miss
Customer Name
*
Customer's Gender
Male
Female
Transgender
Date of Birth
*
Email ID
*
Customer Mobile No
*
Marrital Status
*
Select Option
Married
Single
Divorced
Seperated
Widow/Widower
Widowed
Other
CASA/Loan AC/AAN NO:
*
Address
Pincode
*
Address Line 1
*
Address Line 2
*
Address Line 3(Area)
City
State
Area (as per PF)
Corresponding Addess same as Permanent Address
Corresponding Address
Pincode *
Address Line 1*
Address Line 2*
Address Line 3(Area)
City
State
Area (as per PF)
Bajaj Allianz - Flexi Health Protect Plan (Group)
Super Top Up
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Plan Name
Plan1
Plan2
Sum Insured Option
Select Option
3000000
5000000
Deductible
Select Option
300000
500000
Policy Tenure
1 Year
Self
Select Members
Floater
Member Covered
Self
Members Combination
--Select Combination
Self + 1 Child
Self + 2 Child
Self + Spouse
Self + Spouse + 1 Child
Self + Spouse + 2 Child
Customer Name
*
Relation
*
Gender
*
Height(cms)
*
Weight(Kg)
*
DOB
*
AGE
*
Nominee Name
*
Nominee Relation
*
Pre-existing Disease
*
Select Option
Self
Spouse
Son
Daughter
Select Option
Male
Female
Transgender
Select Option
Spouse
Father
Mother
Son
Daughter
Brother
Sister
Legal Gardian
Select Option
No
Yes
Customer Name
*
Relation
*
Gender
*
Height(cms)
*
Weight(Kg)
*
DOB
*
AGE
*
Nominee Name
*
Nominee Relation
*
Pre-existing Disease
*
Select Option
Spouse
CHILD
Select Option
Male
Female
Transgender
Select Option
Spouse
Son
Father
Mother
Daughter
Brother
Sister
Legal Gardian
Select Option
No
Yes
Customer Name
*
Relation
*
Gender
*
Height(cms)
*
Weight(Kg)
*
DOB
*
AGE
*
Nominee Name
*
Nominee Relation
*
Pre-existing Disease
*
Select Option
CHILD
Spouse
Select Option
Male
Female
Transgender
Select Option
Spouse
Son
Daughter
Father
Mother
Brother
Sister
Legal Gardian
Select Option
No
Yes
Customer Name
*
Relation
*
Gender
*
Height(cms)
*
Weight(Kg)
*
DOB
*
AGE
*
Nominee Name
*
Nominee Relation
*
Pre-existing Disease
*
Select Option
Spouse
CHILD
Select Option
Male
Female
Transgender
Select Option
Spouse
Father
Mother
Son
Daughter
Brother
Sister
Legal Gardian
Select Option
No
Yes
Customer Name
*
Relation
*
Gender
*
Height(cms)
*
Weight(Kg)
*
DOB
*
AGE
*
Nominee Name
*
Nominee Relation
*
Pre-existing Disease
*
Select Option
Spouse
CHILD
Select Option
Male
Female
Transgender
Select Option
Spouse
Father
Mother
Son
Daughter
Brother
Sister
Legal Gardian
Select Option
No
Yes
Customer Name
*
Relation
*
Gender
*
Height(cms)
*
Weight(Kg)
*
DOB
*
AGE
*
Nominee Name
*
Nominee Relation
*
Pre-existing Disease
*
Select Option
Spouse
CHILD
Select Option
Male
Female
Transgender
Select Option
Spouse
Father
Mother
Son
Daughter
Brother
Sister
Legal Gardian
Select Option
No
Yes
Calculate Premium
Save Member details
Member Pre existing Disease is Yes, We can not issue policy. Please contact nearest branch
Final Premium
Reference ID
Lead Status
Lead Sub Status
Do you want Standing Instructions for this product
Coverages under the policy:
1. In-patient Hospitalisation Treatment 2. Pre-Hospitalisation 3. Post-Hospitalisation 4. Road Ambulance 5. Day Care Procedures, Organ Donor Expenses
6. Sum Insured Reinstatement Benefit 7. Hospital Cash Benefit 8. Preventive Health Check Up 9. Ayurvedic / Homeopathic Hospitalization Expenses
Do you or any of the family members who need to be covered have/had any health complaints, have met with an accident or were hospitalised in the period prior to taking this policy?*
Yes
NO
Are you or any of the family members to be covered under any form of mediation for any illness/diseases?*
Yes
NO
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Resend OTP
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Status
Quote Generated