Form Input Data Have you suffered from any of the following disease? Heart related disease No Yes Kidney related disease No Yes Brain disorder No Yes Cancer No Yes Submit Sorry!!! You are not eligible to buy Religare Secure Plan Congratulations!!! You are eligible to buy Religare Secure Plan Please fill up the below form Title Mr Mrs Ms Name Date of Birth Gender Male Female Mobile Number Email ID Highest Educational Qualification: Annual Income: Does your job require you to engage in significant manual labor or hazardous activities or requires handling hazardous material or working at significant heights or with high voltage No Yes Have you ever been diagnosed or are under treatment for any terminal illness or any illness/disease restricting your activities (e.g. Epilepsy/Seizure disorder) No Yes Any existing Disability/Deformity (physical or mental impairment/infirmity or any condition hampering vision, hearing or mobility) No Yes Has any company ever declined to issue/renew a Personal Accident policy for any proposed? If yes, please provide details No Yes Sum Assured: (Minimum Rs. 10 Lacs)
