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REGISTRATION

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IMPORTANT

Mobile Number is required to call back.
Email ID, Mailing Address are required to send you a copy of this form and correspondence regarding your policy. Date of Birth, Gender, Work Activity is required for use to ensure we pay the correct Insurance Premium.

Policy is activated only for Basic, Premium & Limited Plans.

Your Information

Your Emergency Contacts

Mobile Number is required to call the Emergency Contact.
Choose up to 6 Emergency Contacts from any country

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