Please Fill Complete Proposal Form (Health Insurance Proposal Form)

Please Note: All Plans are Standard Plans; for Complete Plan Details Please visit Insurance Company Website.

Payment Details

Account Name Bank Name Branch Name Current Account No. IFSC Code MICR Code
A2Z ASSURANCE PRIVATE LIMITED ICICI Bank Ltd. Hisar Red Square Market 661605601215 ICIC0006616 125229103

Proposer Details

Details of Persons to be Insured