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2026-2027 - Sanjivani Medical Sahay Registration Form

First Name

Father Name

Grand Father Name

Surname

Bhujpur Membership No

Name of Sheri in KUTCH

Home Address

Mobile No

Phone No

Sanjeevani / Vado mahajan Membership no

Occupation

Office/Company Address

Adhar Card No

PAN Card

Please upload clear scanned copies of the following documents. Allowed formats: JPG, PNG, PDF. Max size: 5MB each.

📄 Sanjivani Receipt: (Will be saved as: MEMBERSHIPNO_sanjivani)

Upload Sanjivani Medical Receipt/Policy document

🪪 Aadhar Card: (Will be saved as: MEMBERSHIPNO_aadhar)

Upload clear copy of Aadhar Card (Front & Back if possible)

📋 Cheque Photo: (Will be saved as: MEMBERSHIPNO_cheque)

Upload Ration Card copy

⚡ Electricity Bill: (Will be saved as: MEMBERSHIPNO_electric)

Upload recent Electricity Bill (for address proof)

મેડિકલ ક્લેઇમ કંપની (કોઈ પણ એક પોલિસી ના પ્રીમિયમ મા સહાય અપવામાં આવશે)

If Floater policy then mention Total Policy Amount and Premium Amount - SANJIVANI / IFFCO-TOKYO

If Floater policy then mention Total Policy Amount and Premium Amount ( PRIVATE )

individual Policy Holder Details on (Not for Floter policy)

Total Premium Amount:

Amount Approval Amount: