Sanjivani Medical Sahay Registration Form - 2024

  

      
Form size limit is 5120kB Upload following files in .jpg format only

note : ફાઈલ નામ પહેલા તમારા નામ અને સરનેમ લખો 
for example : pankajdedhia-sanjivanireceipt.jpg  or pankajdedhia-adharcard.jpg  / pankajdedhia-rationcard.jpg

Sanjivani/Vado Mahajan/Private Receipt :
Adhar Card :                                                        
Cheque Photo  :                                                  
Current Electricity Bill Photo  :                       

First Name Father Name Grand Father Name Surname

Bhujpur Seva Samaj Membership No    

Name of Sheri in KUTCH

Home Address

 

Mobile No

 

Sanjeevani/ Vado Mahajan  Membership no

    

 

      

Occupation

Office/Company Address

Aadhar Card No

Phone No
PAN Card No   
       

please put the sum assured amount. it is compulsory if you do not put sum assured amount then your form will not be process.

બધા મેમ્બર્સ ને સંજીવની પોલિસી નો sum assured ફરજીયાત નાખવનું છે જો તમે નહીં લખો તો તમારો ફોર્મ માન્ય નહિ થાય

તમારી પાસે કોનું મેડિકલેઇમ છે           (koyi pan  ek policy na premium ma sahay aap vama apvse )

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

If Floater policy then mention Total Policy Amount and Premium Amount   ( IFICO-TOKYO)

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

Family Details ( For Individual Policy only )

SR Full Name Relation with Applicant Profession Yearly Income Age

Sum
Assured  

Premium Amount

 Bhujpur Membership no
1

2

3

4

5

6

 

  

                                       
                                     Total Premium Amount
                      

Name of Proposal Account    
Bank Name    
Branch Name    
Account No    
IFSC Code