VON SAFE PAY

INSURANCE FORM

Health Insurance

Would You Like to be Insured(Add Members)

Choose From Them

No of Child

Age

Name:

Date of Birth:

Gender:

Email:

Mobile No.:

City:

State/Province

Pin Code

Education level:

Annual Income:

Occupation Type:

Sum Insured:

Hospitalize:

Tenure:

Identity Proof:

Aadhar Card*

Pan Card

Photo(Applicant)*

Discharge Summary

Other