Custom Form – Smart Insurance Bazaar

Your Information

Please fill out all the mandatory fields those marked with *, applicable for insurance you opt. if not applicable, please mention N/A

Your Name *

Your Email *

Your Alternate Email Id*

Contact *

Alternate Contact *

Select Gender *

Date of Birth *

Address of Residence for Communication *

Select State *

Select City *

Pincode *

Annual Income Range (INR)

Any Additional Remarks

Please fill out all the mandatory fields those marked with *,
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Please fill out all the mandatory fields those marked with *, applicable for insurance you opt. if not applicable, please mention N/A

I want to *

Select Insurance

Life

Health

Travel

Home

Life Insurance

Type of Life & Allied Insurance you Require * Combo plans with Life & Health insurance Term insurance Zero Cost Term insurance Whole Life insurance plans Endowment / Savings / Moneyback Assurance Plans Money Back Plans Unit Linked Insurance Plans Child Savings Plans Annuity / Pension Plans Retirement Plans Guaranteed Return Plans Critical illness Benefit Rider Hospital Daily cash Benefit Rider Personal Accident insurance Rider Critical illness indemnity Rider Other

Life insurance Coverage upto the age of *

Budget for Life Insurance Premium [per year]

Nos. of Years You would like to contribute in paying premium for investment

When Do you require Returns on Investments. (please note - more the deferment period, more the benefits you get)

Life insurance companies you prefer Max Life TATA AIA Life HDFC Life Bajaj Allianz Aditya Birla Sun Life SBI Life LIC Kotak Life ICICI Prudential Life Bharti Axa Life Any other Life insurance cos.

Required Sum insured of insurance coverage?*

Health Insurance

Type Health & Allied insurance you Require * Standard Health indemnity insurance plans Special Health indemnity insurance plans Advanced Health indemenity insurance plans Super Advanced Health indemenity insurance plans Critical illness indemnity insurance plan Super top up Health insurance plans Critical illness Benefit plans Hospital Daily cash Benefit plans Personal Accident Benefit insurance plans OutPatient Health Care insurance plans Vector borne diseases Benefit plans Overseas Travel or Global Emergency Critical Health plans Combo plans with Life & Health insurance Other

Customise the Features you need in your Basic Health indemnity insurance plan * Coverage of Any ROOM including Suite Single private standard ac room and ICU without capping on rent AYUSH coverage Non medicals coverage Air Ambulance coverage Automatic Restoration - unlimited Automatic Restoration - Limited Modern treatments coverage without limits No sublimits on certain diseases including Catatact Pre existing diseases waiting period- 4yrs Pre existing diseases waiting period- 3yrs Pre existing diseases waiting period- 2yrs Pre existing diseases waiting period- 1yrs Pre existing diseases waiting period- lesser than 1yr Coverage of Dental Treatment Expenses Worldwide Hospitalization Cover 1 Year renewal premium waiver Wellness Promotion and Rewards Coverage of Treatment for infertility Maternity (Delivery) & New borne coverage Health check up costs coverage Fixed Premium Based on Entry Age Carry forward unutilised suminsured Day 1 Coverage for Pre-existing ABCD (Asthma-BP (high) Cholesterol-Diabetes) OutPatient Expenses Coverage Any other Features / Requirements

Renewal due date of Existing Health Policy

System of Medicines, I prefer * Allopathy Ayurveda Homeopathy Unani Siddha Naturopathy Yoga Any Other System of Medicine

Budget for Health Insurance Premium *

Reduce Health insurance premium? by opting? * No Yes, by Co-payment Yes, by annual aggregate Deductible Yes, by per claim Deductible Yes, by sublimits on common surgeries Yes, by Capping of Room Rent & ICU Yes, by Treatment in only a specified Hospitals listed and approved by insurer Yes, by treatment only in non-metropolitan cities

Would you like to opt in paying health insurance premium for policy tenure longer than 1year? *

Health insurance companies you prefer Reliance General insurance co. IFFCO TOKIO General insurance co. SBI General insurance co. Future Generali insurance co. Bajaj Allianz General insurance co. Acko General insurance co. Go Digit General insurance co. Chola MS General insurance co. New India Assurance co. United India insurance co. Oriental insurance co. National insurance co. Zuno General insurance co. Star Health insurance co. Care Health insurance co. Niva Bupa Health insurance co. Manipal cigna Health insurance co. Aditya Birla Health insurance co. Any Other Insurance company

Required Sum insured of insurance coverage? (Health & Life in ₹) (Travel in $) *

Travel Insurance

Purpose of your Travel for which insurance Required * Studies Official international Trip Tour Medical Tourism ( For Advanced Medical or Surgical Treatments ) Job Related Foreign Tour for Visiting Relations Annual Multi-Trip Individual Tour Trip International Family Tour Trip International Others

Customise the Benefits in your Travel insurance plans * Home Insurance Luggage / Baggage Loss or Delay cover Worldwide Hospitalization Cover Loss of passport cover Loss of Travel Fund cover Pre existing diseases coverage Medical Emergency cover Adventure Sports cover Flight Delay / Cancellation cover Trip rescheduling or cancellation cover Coverage of dental consultations & investigations Domiciliary hospitalization Maternity (Delivery) coverage Critical illness benefits Personal accident PA benefit Hospital Cash Benefits Any Other

Countries you are travelling *

Nos. of Days or Months of Trip *

Required Sum insured of insurance coverage?*

Home Insurance

Are You a Tenant or Owner Occupant or Owner of Building occupied by Tenant *

Age of the Building (in years & months) *

Total Current Market value Cost of concrete Buildings to be insured *

Does the building to be insured have any KUTCHA constructions?*

Numbers of Floors in the building *

Carpet Area *

Construction costs per square feet *

Electronics or Portable Equipments or other contents items to be insured * No, Do not want to insure any contents of the Buildings Television Refrigerator Washing Machine Laptops Camera Mobile Phones Jewels Paintings Telephone Others

Costs of above electronics / Equipement/ Portable items *

Type of Coverage Required for your Buildings *

Other add-on covers required? Loss of Rent Loss of Turnover (Profit) Temporary Resettlement or expenses of alternate accommodation Cover Vehicle Keys & Locks Replacement cover ATM withdrawal Robbery cover Lost Wallet cover Public Liability Cover Employees compensation cover Dog Insurance cover Compound Wall & other Grounds cover Burglary Theft Terrorism RSMD - Riot, Strike, Malicious Damage Money Cover Personal Accident Public Liability Fidelity Guarantee Baggage cover Plate Glass & Saniatry Fittings cover Neon sign / Glow sign / Hoarding Removal of Debris Forest Fire Spontaneous combustion Leakage and Contamination cover Impact damage due to own vehicles, equipments, Cranes, Fork Lifts, Stackers and the like and articles dropped there from Cover the omission to insure additions, alterations or extensions Waiver of Subrogation Others

Required Sum insured of insurance coverage for Your Property? *

Insurance companies you would like to Choose * HDFC Ergo General insurance co. ICICI Lombard General insurance co. Kotak General insurance co. TATA AIG General insurance co. Royal Sundaram General insurance co. Reliance General insurance co. IFFCO TOKIO General insurance co. SBI General insurance co. Future Generali insurance co. Bajaj Allianz General insurance co. Acko General insurance co. Go Digit General insurance co. Chola MS General insurance co. New India Assurance co. United India insurance co. Oriental insurance co. National insurance co. Zuno General insurance co. Any Other General insurance company

Would You like to opt in paying Home insurance premium for Longer Tenure Policy? *

Please fill out all the mandatory fields those marked with *,
applicable for insurance you opt. if not applicable, please mention N/A

Please fill out all the mandatory fields those marked with *, applicable for insurance you opt. if not applicable, please mention N/A

DETAILS OF MEMBERS TO BE INSURED:

Add Member

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applicable for insurance you opt. if not applicable, please mention N/A

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PERSONAL PROTECTION INSURANCE

Your Information