Medical Insurance Application Form

All * marked fields are mandatory.

PROPOSER INFORMATION

* Title

* Name

* Citizenship ID card

* Date of birth

* Gender

* Marital Status

* Occupation

* Email address

* Mobile:

* TPN number

PRESENT ADDRESS

* Village

Dungkhag

* Dzongkhag

* Country

PERMANENT ADDRESS

* Village

Dungkhag

* Gewog

* Dzongkhag

NOMINEE DETAILS

* Name

* Citizenship ID card

* Relationship

FAMILY PHYSICIAN DETAILS

Name

Mobile

Clinic name

* Medical report Click here to download the medical form. 45 years and below applicant can fill up, sign and attach.

Additional Medical report * It is mandatory for 46 years old and above to submit this report. Click here to download

DETAILS OF THE INSURANCE PLAN

* Mandatory Covers: Hospitalization + Ambulance Cover + 2 Years PED

* Plan options

* Sum insured

* Insurer 1 must be the oldest family member.

* Name

* Gender

* Date of birth

* Relationship with proposer

Name

Gender

Date of birth

Relationship with proposer

Name

Gender

Date of birth

Relationship with proposer

Name

Gender

Date of birth

Relationship with proposer

Name

Gender

Date of birth

Relationship with proposer

Medical Insurance Application Form

PROPOSER INFORMATION

PRESENT ADDRESS

PERMANENT ADDRESS

NOMINEE DETAILS

FAMILY PHYSICIAN DETAILS

DETAILS OF THE INSURANCE PLAN

DETAILS OF PERSONS TO BE INSURED - INSURED 1

DETAILS OF PERSONS TO BE INSURED - INSURED 2

DETAILS OF PERSONS TO BE INSURED - INSURED 3

DETAILS OF PERSONS TO BE INSURED - INSURED 4

DETAILS OF PERSONS TO BE INSURED - INSURED 5