{"id":2201,"title":"WOMEN SPECIFIC CRITICAL ILLNESS PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/digital-pf/Women-Critial-Illness-PF-Final.pdf","sha256":"584e939a0cd886728f72ebd542ed9e7202e8c6f654c3e253cdb12eb662cf6531","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for a Women Specific Critical Illness insurance policy with Bajaj General Insurance Limited. The proposer fills this form to provide personal, health, nominee, and payment details for underwriting and policy issuance.","notes":["Please answer all questions in BLOCK letters.","Liability of the company commences only after acceptance of proposal and payment of premium.","Provide all information fully and accurately; non-disclosure may lead to policy being void.","Nominee for self must be one of the specified relations: Father, Mother, Son, Daughter, Spouse, or Other.","Attach original or copies of medical reports if applicable.","Use block letters to fill the form.","If the proposer is disabled, an authorized representative may sign on their behalf.","The form includes an acknowledgment section for receipt of payment but submission does not guarantee policy issuance."],"title":"WOMEN SPECIFIC CRITICAL ILLNESS PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter your full name with title in block letters","type":"text","label":"Full Name : Title First Name Middle Name Surname","options":[],"required":true,"pdf_field":"Title, First Name, Middle Name, Surname"},{"help":"Enter existing policy number if any","type":"text","label":"the Policy No.: OG","options":[],"required":false,"pdf_field":"Policy No OG"},{"help":"Enter PID number if existing customer","type":"text","label":"Existing Customer (PID) No.","options":[],"required":false,"pdf_field":"PID NO"},{"help":"","type":"checkbox","label":"I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy","options":["I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender: Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":"DOB"},{"help":"Enter your PAN number","type":"text","label":"Pan No.","options":[],"required":false,"pdf_field":"Pan No"},{"help":"Enter last 4 digits of Aadhaar number","type":"text","label":"Aadhaar No. Enter last 4 digits only","options":[],"required":false,"pdf_field":"Aadhaar No"},{"help":"Select your marital status","type":"choice","label":"Marital Status: Married Single Divorced Widowed","options":["Married","Single","Divorced","Widowed"],"required":true,"pdf_field":""},{"help":"Enter number of sons and daughters","type":"text","label":"No. of children: Sons Daughters","options":[],"required":false,"pdf_field":""},{"help":"Select your occupation","type":"choice","label":"Occupation Business Salaried Professional Student House wife Retired Other","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide ABHA number(s) for insured persons if applicable","type":"table","label":"If Yes please share your Ayushmaan Bharat Health Account Number (ABHA) in below table","options":[],"required":false,"pdf_field":"ABHA Number101.0, ABHA Number101.1, ABHA Number101.2, ABHA Number101.3, ABHA Number101.4"}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Enter full communication address and contact details","type":"text","label":"Communication Address (all communications will be sent to below): House No. House Name Landmark/Locality Road/Area Name City/District State Pin Code Telephone Mobile Email","options":[],"required":true,"pdf_field":"House No1, House Name_2, LandmarkLocality_2, RoadArea Name, CityDistrict_2, State_2, Pin Code1, TelephoneNo1, MobileNo1, Email_2"}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"Select highest educational qualification","type":"choice","label":"Educational Qualification: Matriculate Undergraduate Graduate Post Graduate Professionally Qualified","options":["Matriculate","Undergraduate","Graduate","Post Graduate","Professionally Qualified"],"required":false,"pdf_field":""},{"help":"Enter your nationality","type":"text","label":"Nationality","options":[],"required":true,"pdf_field":"Nationality"},{"help":"Enter monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":"Monthly Income"},{"help":"Select policy term","type":"choice","label":"Policy Term: 1 Year 2 Years 3 Years","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Plan Details (Sum Insured Options)","fields":[{"help":"Select sum insured option","type":"choice","label":"Sum Insured Options","options":["Rs. 50,000","Rs. 1,00,000","Rs. 1,50,000","Rs. 2,00,000"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Details","fields":[{"help":"Select yes or no and provide reason if yes","type":"yes-no","label":"Has your Health Insurance / Life Insurance proposal ever been declined? If yes kindly mention the reason below","options":["Yes","No"],"required":true,"pdf_field":"Life insurance Proposal Declined Reason"},{"help":"Select yes or no","type":"yes-no","label":"Are you in good health & entirely free from any mental / physical impairments or deformities?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Unexplained night sweat and/or loss of weight, persistent fever, chronic or recurrent diarrhea, unexplained infections or swollen glands?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Are you now in good health and entirely free from any mental or physical impairments or deformities?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Have you ever suffered from or do you suffer from Diseases of the Nervous system or Mental Disorders e.g. Stroke, Epilepsy, Fits / Fainting attacks, Frequent Headache, Psychiatric Disorders?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Please confirm if you had or currently have - Breast lumps /pain associated with Breast Lumps / discharge from breast other than breast milk /redness, scaliness, or thickening of the nipple or breast skin","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no and provide details if yes","type":"yes-no","label":"Have any of your immediate family members (father, mother, brother or sister) have/ had diabetes, hypertension, cancer, heart attack, or stroke and at what age? If yes, was it before age 60 years or after 60 years?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide family member disease details if applicable","type":"table","label":"Member Name Relationship with Proposer Disease Name At what Age illness suffered","options":[],"required":false,"pdf_field":"Member NameRow1, Relationship with ProposerRow1_2, Disease NameRow1, At what Age illness sufferedRow1"},{"help":"Select yes or no","type":"yes-no","label":"Do you have any abnormality in menstrual cycle - Irregular Menstrual Cycle Heavy bleeding Ovulatory disorders Pelvic Inflammatory Disease Any other diseases / disorders /complaints of Reproductive system","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no and provide duration if yes","type":"yes-no","label":"Please confirm if you are pregnant at the time of proposal, if yes, please confirm the No of weeks/months","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Did you have any problems in earlier pregnancies?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no and specify if yes","type":"yes-no","label":"Have you ever suffered from any other disease/illness other than the ones mentioned above?","options":["Yes","No"],"required":true,"pdf_field":"Other Disease"},{"help":"Select yes or no and attach reports if yes","type":"yes-no","label":"In past 4 years have you ever consulted a Doctor or under gone any test like Ultra Sonograms, CT Scan, 2D Echocardiography, ECG, or Biopsy? If Yes, please provide the reports","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no and provide details if yes","type":"yes-no","label":"Do you smoke cigarettes or consume tobacco (chewing paste) / alcohol, nicotine or marijuana in any form? Please give duration and daily consumption?","options":["Yes","No"],"required":true,"pdf_field":"daily consumption"},{"help":"Select yes or no","type":"yes-no","label":"Has any of the persons to be insured suffer from/or investigated for any of the following? Disorder of the heart, or circulatory system, chest pain, high blood pressure, stroke, asthma any respiratory conditions, cancer tumor lump of any kind, diabetes, hepatitis, disorder of urinary tract or kidneys, blood disorder, any mental or psychiatric conditions, any disease of brain or nervous system, fits (epilepsy) slipped disc, backache, any congenital/ birth defects/ urinary diseases, AIDS or positive HIV.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Have you ever been advised by the Doctor for Hospital admission/treatment or Surgery or to be on regular medication?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide detailed medical history for any yes answers and attach reports","type":"table","label":"If your answer to any of the above is YES, please provide complete details of the illness/disease/condition in the table below (Attach extra sheet if required): Name of the person Details of disease/illness/injury suffering from Month and year when first treated Name of attending Medical Practitioner / Surgeon with address and telephone no. If completely cured/ Currently under treatment?","options":[],"required":false,"pdf_field":"Name of the personRow1, Details of diseaseillness injury suffering fromRow1, Month and year when first treatedRow1, Name of attending Medical Practitioner  Surgeon with address and telephone noRow1, If completely cured Currently under treatmentRow1"}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"Select payment mode","type":"choice","label":"Payment Mode Full Payment Instalment Payment Monthly Quarterly Half Annual","options":["Full Payment","Instalment Payment"],"required":true,"pdf_field":""},{"help":"Select payment mode","type":"choice","label":"Payment Details Cash Cheque DD Credit Card Debit Card UPI","options":["Cash","Cheque","DD","Credit Card","Debit Card","UPI"],"required":true,"pdf_field":""},{"help":"Select who gave the cheque if applicable","type":"choice","label":"Cheque Given By Spouse Father Mother Son/Daughter Financer Employer/Employee","options":["Spouse","Father","Mother","Son/Daughter","Financer","Employer/Employee"],"required":false,"pdf_field":""},{"help":"Tick if paying through BIMA ASBA facility","type":"checkbox","label":"BIMA ASBA Declaration (Applicable only in case Premium payment through online payment mode)","options":["under the BIMA ASBA facility and debit the same from my bank account upon acceptance of this proposal. In case the proposal is not accepted, I accord my consent to debit only the expenses incurred towards medical examination, if any, and unblock the balance amount"],"required":false,"pdf_field":""},{"help":"Enter amount paid","type":"amount","label":"Amount","options":[],"required":false,"pdf_field":"Amount"},{"help":"Enter transaction number","type":"text","label":"Transaction No","options":[],"required":false,"pdf_field":"Transaction No"},{"help":"Enter transaction date","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":"TransationDate"},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":"Bank Name"},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":false,"pdf_field":"Branch"},{"help":"Tick yes or no to open e-IA account","type":"yes-no","label":"Electronic-Insurance Account Please provide e-IA No. to deposit your insurance policy. Do you want to open e-IA account Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select preferred contact mode for offers","type":"choice","label":"In case of any Offer, you would prefer to be contacted by: Phone Email WhatsApp","options":["Phone","Email","WhatsApp"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration and Signatures","fields":[{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":"Date 4"},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":"Place 4"},{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":"Signature Impression Of The Proposer"},{"help":"Intermediary to sign","type":"signature","label":"Signature of Intermediary","options":[],"required":true,"pdf_field":"Signature Of Intermediary"},{"help":"Enter witness name if applicable","type":"text","label":"Name of Witness","options":[],"required":false,"pdf_field":"Name Of Witness"},{"help":"Witness signature if applicable","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":"Signature Of Witness"},{"help":"Declare any physical disability and provide certificate if yes","type":"yes-no","label":"Disability Declaration Any Physical deformity or handicap? Yes/No If Yes. Please provide details","options":["Yes","No"],"required":false,"pdf_field":"Disability Certificate"},{"help":"If proposer is disabled, authorized representative details","type":"text","label":"Name of Authorised Representative","options":[],"required":false,"pdf_field":"Name Of Authorised Representative"},{"help":"Date of authorized representative signature","type":"date","label":"Date","options":[],"required":false,"pdf_field":"Date 5"},{"help":"Place of authorized representative signature","type":"text","label":"Place","options":[],"required":false,"pdf_field":"Place 5"},{"help":"Agent or IMD name","type":"text","label":"Agent/IMD Name","options":[],"required":true,"pdf_field":"Agent Name"},{"help":"Agent or IMD code","type":"text","label":"Agent/IMD Code","options":[],"required":true,"pdf_field":"Agent Code"},{"help":"Agent or IMD signature","type":"signature","label":"Agent/IMD Signature","options":[],"required":true,"pdf_field":"Signature Of Agent"},{"help":"Name of sales point or intermediary","type":"text","label":"SP / BQP / DP / PoS Name","options":[],"required":false,"pdf_field":"SP / BQP / DP / PoS Name"},{"help":"Code of sales point or intermediary","type":"text","label":"SP / BQP / DP / PoS CoR No.","options":[],"required":false,"pdf_field":"SP / BQP / DP / PoS No"},{"help":"Signature of sales point or intermediary","type":"signature","label":"SP / BQP / DP / PoS Signature","options":[],"required":false,"pdf_field":"SP/BQP/DP/PoS Sign"}],"filled_by":"proposer and intermediary"}],"deadlines":[],"applies_to":"Women Specific Critical Illness insurance proposal","attachments":["Copies of investigation reports / consultation letters / Discharge summary (If available)","Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability"],"declarations":["The statements and particulars given are true and complete to the best of the proposer's knowledge.","The policy will come into force only after full payment of the premium.","The proposer will notify any change in occupation or health after submission but before acceptance.","Consent is given to the company to seek medical information from doctors, hospitals, employers, and insurers for underwriting and claims.","Consent is given to collect and share personal and medical information from Ayushman Bharat Health Account (ABHA) for underwriting and claims.","Agent declares that the proposal form contents have been explained to the proposer in vernacular language if required.","Premiums are paid from legally acquired sources of income.","No person shall offer or accept rebates as inducement for insurance contrary to Insurance Act 1938 Section 41."],"dropped_labels":7},"pdf_fields":[{"name":"Scrutiny No","page":1,"type":"text","label":"Scrutiny No._Row_1"},{"name":"Receipt No","page":1,"type":"text","label":"Receipt No._Row_1"},{"name":"Policy No","page":1,"type":"text","label":"Policy No._Row_1"},{"name":"Loan Account No","page":1,"type":"text","label":"Loan Account Number_Row_1"},{"name":"EmpLG No","page":1,"type":"text","label":"Emp/LG Code_Row_1"},{"name":"IMD Code","page":1,"type":"text","label":"IMD Code_Row_1"},{"name":"Sub IMD Code","page":1,"type":"text","label":"Sub IMD Code_Row_1"},{"name":"IMD NameRow1","page":1,"type":"text","label":"IMD Name_Row_1"},{"name":"MobileNO","page":1,"type":"text","label":"Mobile_Row_1"},{"name":"Title","page":1,"type":"text","label":"First Name"},{"name":"First Name","page":1,"type":"text","label":"First Name"},{"name":"Middle Name","page":1,"type":"text","label":"First Name"},{"name":"Surname","page":1,"type":"text","label":"First Name"},{"name":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Policy No OG","page":1,"type":"text","label":"a. The Policy No.: OG"},{"name":"PID NO","page":1,"type":"text","label":"b. Existing Customer (PID) No"},{"name":"Group No2","page":1,"type":"radiobutton"},{"name":"Group No3","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No3","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No3","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"DOB","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Pan No","page":1,"type":"text","label":"First Name"},{"name":"Aadhaar No","page":1,"type":"text","label":"Enter last 4 digits only"},{"name":"Employee Code","page":1,"type":"text","label":"7.Bajaj Allianz Employee Code , if Proposer is BAGIC/BALIC  Employee"},{"name":"Group No4","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1","Choice1"]},{"name":"Group No4","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1","Choice1"]},{"name":"Group No4","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1","Choice1"]},{"name":"Group No4","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1","Choice1"]},{"name":"NoC1","page":1,"type":"text","label":"Place"},{"name":"NoC1","page":1,"type":"text","label":"Place"},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Other","page":1,"type":"text","label":"Occupation  Business  Salaried  Professional  Student  House wife  Retired  Other"},{"name":"Group No66666","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Group No66666","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"House No","page":1,"type":"text","label":"House Name"},{"name":"House Name","page":1,"type":"text","label":"House Name"},{"name":"House No1","page":1,"type":"text","label":"House Name"},{"name":"House Name_2","page":1,"type":"text","label":"House Name"},{"name":"LandmarkLocality","page":1,"type":"text","label":"Landmark/Locality"},{"name":"LandmarkLocality_2","page":1,"type":"text","label":"Landmark/Locality"},{"name":"RoadArea Name","page":1,"type":"text","label":"Road/Area Name"},{"name":"CityDistrict_2","page":1,"type":"text","label":"City/District"},{"name":"CityDistrict","page":1,"type":"text","label":"City/District"},{"name":"CityDistrict_2","page":1,"type":"text","label":"City/District"},{"name":"State","page":1,"type":"text","label":"State"},{"name":"State_2","page":1,"type":"text","label":"State"},{"name":"Pin Code","page":1,"type":"text","label":"Pin Code:"},{"name":"Pin Code1","page":1,"type":"text","label":"Pin Code:"},{"name":"TelephoneNo","page":1,"type":"text","label":"Telephone"},{"name":"MobileNo","page":1,"type":"text","label":"Mobile"},{"name":"TelephoneNo1","page":1,"type":"text","label":"Telephone"},{"name":"MobileNo1","page":1,"type":"text","label":"Mobile"},{"name":"Email","page":1,"type":"text","label":"Email"},{"name":"Email_2","page":1,"type":"text","label":"Email"},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Nationality","page":1,"type":"text","label":"undefined"},{"name":"Monthly Income","page":1,"type":"text","label":"undefined"},{"name":"DOB FROM","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Group No9","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No9","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No9","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"DOB TO","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"M1.1","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.0.0","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.0.0","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.0.0","page":1,"type":"text","label":"Age_(dd/mm"},{"name":"Ht.0.0","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0.0","page":1,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Details.0","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"Premium.0","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"ABHA Number101.0","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M1.2","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.0.1","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.0.1","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.0.1","page":1,"type":"text","label":"Age_(dd/mm"},{"name":"Ht.0.1","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0.1","page":1,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Details.1","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"Premium.1","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"ABHA Number101.2","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M1.0","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.0.2","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.0.2","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.0.2","page":1,"type":"text","label":"Age_(dd/mm"},{"name":"Ht.0.2","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0.2","page":1,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Details.2","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"Premium.2","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"ABHA Number101.3","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M1.3","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.0.3","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.0.3","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.0.3","page":1,"type":"text","label":"Age_(dd/mm"},{"name":"Ht.0.3","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0.3","page":1,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Details.3","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"Premium.3","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"ABHA Number101.4","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M1.4","page":1,"type":"text","label":"Ht. 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