{"id":2462,"title":"Nidaan Swasthya Bima Policy 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/Nidaan-Swasthya-Bima-Proposal-Form.pdf","sha256":"bcdf82e18fd23dce139defc8cb6ec9e7e2ca78e856fcd92e6ff0dc8ff38657e3","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals applying for the Nidaan Swasthya Bima health insurance policy, designed especially for Persons with Disability and Persons with HIV/AIDS. The proposer (applicant) fills this form.","notes":["Answer all questions in BLOCK letters.","Only Indian Nationals can be covered under this policy.","Persons with Disability must have 40% disability certified by competent authority as per Disability Act 2016.","Persons with HIV/AIDS must have CD4 count above 400 to be covered.","Fields marked with asterisk (*) are mandatory.","Nominee for self (primary insured) must be one of Father, Mother, Son, Daughter, Spouse, or Other.","For all family members, primary insured will be the nominee.","Use original certificates for CD4 count and disability proof.","The proposal is not accepted and coverage not effective until premium is paid and realized by the insurer.","If the proposal form is not filled by the proposer or proposer does not know English, intermediary must explain the form in vernacular language and sign.","No rebate of commission or premium is allowed except as per published prospectus or tables.","Submission of proposal or payment does not oblige the company to issue a policy."],"title":"Nidaan Swasthya Bima Policy Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter your full name 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":"","type":"choice","label":"Gender: Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":"Gender"},{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":"DOB"},{"help":"Enter 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":"","type":"choice","label":"Marital Status: Married Single Divorced Widowed","options":["Married","Single","Divorced","Widowed"],"required":false,"pdf_field":"Marital"},{"help":"Enter number of sons and daughters","type":"number","label":"No. of children: Sons Daughters","options":[],"required":false,"pdf_field":"Son, Daughters"},{"help":"If Other, specify","type":"choice","label":"Occupation Business Salaried Professional Student House wife Retired Other","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":false,"pdf_field":"Occupation"},{"help":"If Yes, provide ABHA number below","type":"yes-no","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter ABHA number if registered","type":"text","label":"Ayushmaan Bharat Health Account Number (ABHA)","options":[],"required":false,"pdf_field":"ABHA Number101.0"}],"filled_by":"proposer"},{"title":"Permanent / Residential Address","fields":[{"help":"","type":"text","label":"House No.","options":[],"required":true,"pdf_field":"House No"},{"help":"","type":"text","label":"House Name","options":[],"required":true,"pdf_field":"House Name"},{"help":"","type":"text","label":"Landmark/Locality","options":[],"required":true,"pdf_field":"LandmarkLocality"},{"help":"","type":"text","label":"Road/Area Name","options":[],"required":true,"pdf_field":"RoadArea Name"},{"help":"","type":"text","label":"City/District","options":[],"required":true,"pdf_field":"CityDistrict"},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":"State"},{"help":"","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":"Pin Code"},{"help":"","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":"TelephoneNo"},{"help":"","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":"MobileNO"},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":"Email"}],"filled_by":"proposer"},{"title":"Communication Address","fields":[{"help":"","type":"text","label":"House No.","options":[],"required":true,"pdf_field":"House No1"},{"help":"","type":"text","label":"House Name","options":[],"required":true,"pdf_field":"House Name_2"},{"help":"","type":"text","label":"Landmark/Locality","options":[],"required":true,"pdf_field":"LandmarkLocality_2"},{"help":"","type":"text","label":"Road/Area Name","options":[],"required":true,"pdf_field":"Road/Area Name2"},{"help":"","type":"text","label":"City/District","options":[],"required":true,"pdf_field":"CityDistrict_2"},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":"State_2"},{"help":"","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":"Pin Code1"},{"help":"","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":"TelephoneNo1"},{"help":"","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":"MobileNo1"},{"help":"","type":"email","label":"Email","options":[],"required":false,"pdf_field":"Email_2"}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"Policy type is individual basis","type":"text","label":"Policy Type: Individual Basis","options":[],"required":true,"pdf_field":""},{"help":"Policy period is one year","type":"text","label":"Policy period: 1 year","options":[],"required":true,"pdf_field":""},{"help":"Enter start and end date of insurance period","type":"date","label":"Period of Insurance: From To","options":[],"required":true,"pdf_field":"DOB FROM, DOB TO"},{"help":"Select sum insured amount","type":"choice","label":"Sum Insured (Rs.): 4,00,000 5,00,000","options":["4,00,000","5,00,000"],"required":true,"pdf_field":"Sum Insured"},{"help":"Select if waiver of co-pay is opted","type":"yes-no","label":"Waiver of Co-pay opted: Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select coverage option","type":"choice","label":"Coverage opted: Pre-existing HIV/AIDS Pre-existing Disability Pre-existing HIV/AIDS and Disability","options":["Pre-existing HIV/AIDS","Pre-existing Disability","Pre-existing HIV/AIDS and Disability"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details Of Persons To Be Insured","fields":[{"help":"Enter full name of each insured person","type":"text","label":"Name of Insured","options":[],"required":true,"pdf_field":"Insured Name"},{"help":"Enter nationality","type":"text","label":"Nationality","options":[],"required":true,"pdf_field":"NationalityRow1"},{"help":"Specify relationship with primary insured","type":"text","label":"Relationship with Insured","options":[],"required":true,"pdf_field":"Realtionship"},{"help":"Enter date of birth","type":"date","label":"DOB (dd/mm/yyyy)","options":[],"required":true,"pdf_field":"DOB 1111"},{"help":"Enter age in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":"Age"},{"help":"Select gender","type":"choice","label":"Gender (M/F)","options":["M","F"],"required":true,"pdf_field":"Gender"},{"help":"Enter height in centimeters","type":"number","label":"Ht. (cms)","options":[],"required":false,"pdf_field":"Ht"},{"help":"Enter weight in kilograms","type":"number","label":"Wt. (kgs)","options":[],"required":false,"pdf_field":"Wt"},{"help":"Enter occupation","type":"text","label":"Occupation","options":[],"required":false,"pdf_field":"Occupation"},{"help":"Select marital status","type":"choice","label":"Marital Status","options":["Married","Single","Divorced","Widowed"],"required":false,"pdf_field":"Marital"},{"help":"Enter ABHA number if available","type":"text","label":"ABHA Number","options":[],"required":false,"pdf_field":"ABHA Number101.0"}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee's full name","type":"text","label":"Name","options":[],"required":true,"pdf_field":"NomineeName"},{"help":"Enter nominee's date of birth","type":"date","label":"DOB (dd/mm/yyyy)","options":[],"required":true,"pdf_field":"Nominee DOB"},{"help":"Enter nominee's age","type":"number","label":"Age","options":[],"required":true,"pdf_field":"AgeNominee"},{"help":"Enter relationship of nominee to proposer","type":"text","label":"Relation","options":[],"required":true,"pdf_field":"RelationNominee"},{"help":"Enter appointee details if nominee is minor","type":"text","label":"Appointee (If nominee is minor)","options":[],"required":false,"pdf_field":"Appointee Name"},{"help":"Specify relationship and reason if nominee is 'Others'","type":"text","label":"If Nominee is Others please specify the relationship and reason","options":[],"required":false,"pdf_field":"If Nominee is Others please specify the relationship and reason"}],"filled_by":"proposer"},{"title":"Previous/Existing Health Details of Insured","fields":[{"help":"","type":"yes-no","label":"Do you suffer from HIV/AIDS? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach recent CD4 count certificate","type":"attachment","label":"If Yes, please enclose a recent certificate of your current CD4 count (within past 30 days)","options":[],"required":false,"pdf_field":""},{"help":"Enter current CD4 count","type":"number","label":"Current CD 4 count","options":[],"required":false,"pdf_field":"Current CD 4 count"},{"help":"If yes, specify when and how many times","type":"yes-no","label":"Has your CD4 Count gone below 400 in the past 4 years? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details of occurrences","type":"text","label":"If yes when and How many times","options":[],"required":false,"pdf_field":"How Many Times"},{"help":"If yes, attach disability certificate","type":"yes-no","label":"Do you suffer from any disability as per the listed conditions mentioned below: Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, specify details and duration","type":"yes-no","label":"Do you suffer from any pre-existing illness other than Disability or HIV AIDS mentioned above? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide illness details and duration","type":"text","label":"If Yes, please specify details and the no of years you are suffering","options":[],"required":false,"pdf_field":"If Yes please specify details and the no of years you are suffering"}],"filled_by":"proposer"},{"title":"Previous/Existing Health Insurance details","fields":[{"help":"Enter previous policy or application number","type":"text","label":"Policy No. / Application No.","options":[],"required":false,"pdf_field":"Policy No"},{"help":"Enter insurer name","type":"text","label":"Insurer Name","options":[],"required":false,"pdf_field":"Insurer NameRow1"},{"help":"Enter insurance period","type":"date","label":"Period of Insurance (from – to)","options":[],"required":false,"pdf_field":"Period of Insurance (From-To)"},{"help":"Enter sum insured amount","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":"Sum Insured"},{"help":"Provide claim details if any","type":"text","label":"Claims lodged during the preceding years","options":[],"required":false,"pdf_field":"Claims lodged during the preceding years"}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details Section","fields":[{"help":"Select preferred format for insurance information","type":"checkbox","label":"I want related information in Physical Format Yes No e-Format (electronic) as & when applicable Yes No","options":["Physical Format","e-Format (electronic)"],"required":false,"pdf_field":"I want, Information"},{"help":"Select one insurance repository if e-Format chosen","type":"choice","label":"Choose your Insurance Repository","options":["NSDL Data Management Ltd.","CDSL Insurance Repository Ltd","Karvy Insurance Repository Ltd.","CAMS Repository Services Ltd"],"required":false,"pdf_field":""},{"help":"Enter e Insurance Account number if available","type":"text","label":"I have e Insurance Account & the No. is","options":[],"required":false,"pdf_field":"Insurance Account No"},{"help":"Enter CKYC number if available","type":"text","label":"My CKYC No. (Central Know Your Customer registry number) is (If available)","options":[],"required":false,"pdf_field":"CKYC NO"},{"help":"Select if you want to open electronic Insurance Account","type":"yes-no","label":"Do you want to open e-IA account Yes No","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment 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 method","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":"Consent for ASBA payment mode","type":"checkbox","label":"BIMA ASBA Declaration","options":["under the BIMA ASBA facility and debit the same from my bank account upon acceptance of this proposal."],"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"}],"filled_by":"proposer"},{"title":"Bank Details","fields":[{"help":"Enter name as per bank account","type":"text","label":"Name As Per Bank Account","options":[],"required":true,"pdf_field":"Name As Per Bank Account"},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":"Name of the Bank"},{"help":"Enter IFSC code","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":"IFSC Code"},{"help":"Enter bank account number","type":"text","label":"Bank Account No","options":[],"required":true,"pdf_field":"Bank Account No"},{"help":"Enter account type","type":"text","label":"Account Type","options":[],"required":true,"pdf_field":"Account Type"},{"help":"Enter mobile number linked to bank account","type":"phone","label":"Mobile No","options":[],"required":false,"pdf_field":"Mobile No"},{"help":"Enter email address linked to bank account","type":"email","label":"Email Address","options":[],"required":false,"pdf_field":"Email Address"},{"help":"Select preferred contact method 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","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":"Place 4"},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":"Date 4"},{"help":"Signature of agent or intermediary","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":"Signature of witness if applicable","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":"Signature Of Witness"}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"If yes, provide details and attach disability certificate","type":"yes-no","label":"Any Physical deformity or handicap? Yes No","options":["Yes","No"],"required":false,"pdf_field":"Disability Certificate"},{"help":"Provide details of disability","type":"text","label":"If Yes. Please provide details","options":[],"required":false,"pdf_field":""},{"help":"If proposer is disabled, authorised representative fills this","type":"text","label":"Name of Authorised Representative","options":[],"required":false,"pdf_field":"Name Of Authorised Representative"},{"help":"Date of authorised representative's signature","type":"date","label":"Date","options":[],"required":false,"pdf_field":"Date 5"},{"help":"Signature of authorised representative","type":"signature","label":"Signature of Authorised Representative","options":[],"required":false,"pdf_field":"Sign Of Authorised Representative"},{"help":"Place of authorised representative's signature","type":"text","label":"Place","options":[],"required":false,"pdf_field":"Place 5"}],"filled_by":"proposer or authorised representative"},{"title":"Agent Details and Declaration","fields":[{"help":"Enter agent or intermediary name","type":"text","label":"Agent/IMD Name","options":[],"required":true,"pdf_field":"Agent Name"},{"help":"Enter agent code","type":"text","label":"Agent/IMD Code","options":[],"required":true,"pdf_field":"Agent Code"},{"help":"Agent's signature","type":"signature","label":"Agent/IMD Signature","options":[],"required":true,"pdf_field":"Signature Of Agent"},{"help":"Enter name of sales point or business partner","type":"text","label":"SP / BQP / DP / PoS Name","options":[],"required":false,"pdf_field":"SP / BQP / DP / PoS Name"},{"help":"Enter code of sales point or business partner","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 business partner","type":"signature","label":"SP / BQP / DP / PoS Signature","options":[],"required":false,"pdf_field":"SP/BQP/DP/PoS Sign"},{"help":"Date of agent declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":"Date 2"},{"help":"Place of agent declaration","type":"text","label":"Place","options":[],"required":true,"pdf_field":"Place 1"}],"filled_by":"agent"},{"title":"Acknowledgment","fields":[{"help":"Name of proposer acknowledged","type":"text","label":"Received from Ms. / Mrs. / Mr","options":[],"required":false,"pdf_field":"Received from Ms  Mrs Mr"},{"help":"Amount received","type":"amount","label":"Sum of Rs","options":[],"required":false,"pdf_field":"Sum Of Rs"},{"help":"Date of receipt","type":"date","label":"Date","options":[],"required":false,"pdf_field":"Date 333"},{"help":"Time of receipt","type":"text","label":"Time","options":[],"required":false,"pdf_field":"Time"},{"help":"Place of receipt","type":"text","label":"Place","options":[],"required":false,"pdf_field":"Place 2"}],"filled_by":"insurance company"},{"title":"PEP Declaration and KYC Consent","fields":[{"help":"Politically Exposed Persons declaration","type":"yes-no","label":"Are you or any of the proposal applicants a PEP or a close relative of PEP? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details if PEP","type":"text","label":"If yes, please share the details","options":[],"required":false,"pdf_field":"If yes please share the details"}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Persons with Disability (40% disability certified) and Persons with HIV/AIDS with CD4 count above 400","attachments":["Recent certificate of current CD4 count (within past 30 days) if HIV/AIDS positive","Disability certificate mentioning percentage of disability wherever applicable"],"declarations":["The statements made in this form are true and complete to the best of the proposer's knowledge.","The policy will come into force only after full receipt of premium and acceptance of proposal by the company.","The proposer will notify any change in occupation or health after submission but before risk acceptance.","The company may seek medical and other information from hospitals, employers, and other insurers for underwriting and claims.","The company may share proposal and medical information with reinsurers, TPAs, service providers, and regulatory authorities.","The proposer is aware of any premium loading for habits and diseases declared.","The proposer agrees to keep KYC details of all insured members and provide beneficiary details when required.","Agent declares having explained the form contents and consequences of untrue statements or non-disclosure.","Premium has been paid from legally acquired sources and subsequent premiums will be paid similarly.","Consent is given for KYC verification through CERSAI or NSDL portals.","Consent is given or denied for sharing personal information with group companies for marketing."],"dropped_labels":14},"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 Nooo5","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":"Policy No OG","page":1,"type":"text","label":"a. The Policy No.: OG"},{"name":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"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":"Son","page":1,"type":"text","label":"Mobile"},{"name":"Daughters","page":1,"type":"text","label":"Mobile"},{"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":"Road/Area Name2","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":"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":"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":"Group No901","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No901","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No90222","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group 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