Health Insurance Premium Calculation Form

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Please fill up this form, so that we can assess your needs and help you decide the best health insurance plan with optimum premium.

Name *

Email *

Mobile Number *

Date of Birth of Eldest member *

YYYY

Number of adults for whom insurance is needed? *

Please do not include children here even if they are adults.

Number of children for whom insurance is needed? *

Family floater plan should not include children above 25 years old. They need to take separate plan.

Sum Assured you are considering? *

Please provide the amount in Rs lakhs

Any pre-existing illness / past hospitalizations? *

Please provide details for all family members. If none, just write "None".

Your Pincode? *

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