Shree Jain Mahajan Moti Khakhar
(Trust Regi No E-241)
c/o-1302, Kamala Ashish Tower, Mahavir Nagar, Kandivali West, Mumbai - 400067
Application Form For Mediclaim Premium Relief
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Name of Applicant (Proposer Full Name)
*Full Name
(Name_MiddleName_GrandFatherName_Surname)
*Residence Full Address
*WhatsApp Number
*Total No. of Earning Member in Family
*Total Monthly Family Income
Family Member Details
Member 1
Occupation
Monthly Income
Age
Mobile Number
Member 2
Occupation
Monthly Income
Age
Mobile Number
Member 3
Occupation
Monthly Income
Age
Mobile Number
Member 4
Occupation
Monthly Income
Age
Mobile Number
Member 5
Occupation
Monthly Income
Age
Mobile Number
Member 6
Occupation
Monthly Income
Age
Mobile Number
Member 7
Occupation
Monthly Income
Age
Mobile Number
Policy Details
*Policy Type
Sanjeevani
JIO (Vado Mahajan)
Other
*Policy Number / Membership Number
*Total Number of Person In Policy
*Premium Pyament Date
*Premium Amount
*Sum Insured Amount
*If Yes, Name of Organisation
*Will you be returning the above help given back to Jain Mahajan Moti Khakhar in future?
Yes
No
Bank Details
*Bank Name
*Account Holder Name
*Account Number
*IFSC Code
*Branch Name
*Bank Holders Pan Card No
*Upload Photo of Cheque (JPG, PNG, PDF)
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*Upload Premium Payment Reciept (JPG, PNG, PDF)
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Submit