Janata Personal Accident Policy

Primary Insured Details
Date of birth *
Gender *
Sum Insured *
Start date *
End date
Assignee Name*help
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Assignee date of birth
Assignee relation
Name of spouse/father
Name of witness
Employee number
Do you wish to insure another person?
Select Your branch office
OICL Office State *
City/Town *
Branch/Office *
Please select a role to continue
Whether any agent is involved for this proposal?
* If 'NO' is selected, the policy will be issued under code of Development Officer without an Agent.