Nagarik Suraksha Policy

Date of birth *

Gender *

Yearly income *

Disability *

Sum insured *

Start date *

End date

Assignee name *	Assignee relationship *	Share percentage (%) *	Action

Tip: At least one assignee is mandatory

Do you wish to insure your spouse?

Yes

Do you wish to insure your dependent children?

Yes

Do you wish to insure your father?

Yes

Do you wish to insure your mother?

Yes

Select your branch officeOICL Office State *City/Town *Branch/Office *

Email *

Tip: Soft copy of the policy document would be sent to this email address I am a registered portal user and want to pre-populate my personal details. First name *

Middle name

Last name *

Mobile *

Telephone

Date of birth *

GST Number (if any)Occupation *

Address type *

Address for communication *

State *

City *

Pin code *

Declaration *

I/we hereby agree that Oriental insurance company Ltd. can store the personal information/contact details given by me /us in this Basic information form and register me on the portal.

Agree

Disagree

Primary Insured Details

Name of insuredDate of birthGenderAddress for communication StateCityPin codeMobileEmailOccupationYearly incomeDisability typeNASum insured Start date23/08/2017End date22/08/2018

Assignee name	Assignee relationship	Share percentage (%)

Select your branch office

OICL Office StateCity/TownBranch/Office

Premium Without Service TaxService TaxTotal PremiumProposal numberShare proposal detailsEmail

Mobile

Declaration

I/we hereby declare that the statement made by me/us in this proposal form is true to the best of my/our knowledge and belief and I/we hereby agree that this declaration shall form the basis of the contract between me/us and Oriental insurance company Ltd. I/we also hereby declare that if any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the insurer immediately. I/we also understand that if any incorrect details are entered, the claim may not be awarded.

Agree

Disagree

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Yearly income

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