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Insurance contact form
Full Name
*
Mobile Number (WhatsApp Preferred)
*
Current Residential Pincode
*
Who do you want to secure with this plan?
*
Who do you want to secure with this plan?
A
Myself only (Individual)
B
Self + Spouse
C
Self + Spouse + Children (Family Floater)
D
Parents / Parents-in-law
E
Extended Family (More than 4 members)
Age of the Eldest member to be insured?
*
Age of the Eldest member to be insured?
A
18 – 35 Years
B
36 – 45 Years
C
46 – 55 Years
D
56 – 65 Years
E
Above 65 Years
How much "Medical Cover" (Sum Insured) are you looking for?
*
How much "Medical Cover" (Sum Insured) are you looking for?
A
₹5 Lakhs to ₹10 Lakhs (Basic)
B
₹15 Lakhs to ₹25 Lakhs (Standard)
C
₹50 Lakhs to ₹1 Crore (Comprehensive/Super Saver)
D
Unsure, show me the best value plans.
Does any member have a history of the following? (Select all that apply)
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Does any member have a history of the following? (Select all that apply)
A
Diabetes
B
High Blood Pressure (Hypertension)
C
Thyroid
D
Asthma / Respiratory issues
E
No existing medical conditions
Has anyone been hospitalized or had surgery in the last 4 years?
*
Has anyone been hospitalized or had surgery in the last 4 years?
A
Yes
B
No
Does any member smoke or consume tobacco?
*
Does any member smoke or consume tobacco?
A
Yes
B
No
What is your Top Priority for this policy?
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What is your Top Priority for this policy?
A
Lowest Premium (Cheap & Best)
B
Best Hospital Network (Cashless focus)
C
Maternity / New Born Baby Cover
D
Restore Benefit (Refills cover if exhausted)
Do you currently have an active Health Insurance policy?
*
Do you currently have an active Health Insurance policy?
A
No, this is my first policy.
B
Yes, but I want to Switch/Port to a better company.
C
Yes, but I want to add a Top-up for extra cover.
When would you like our expert to share the comparison report?
*
When would you like our expert to share the comparison report?
A
Immediately (Within 15 mins)
B
Today Evening
C
Over the Weekend
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