[REGISTRATION FORM
Receipt No.:
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lame of Proposer
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Address
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Resi No. ( uw ) Incase of Emergency Alternate Contact +91
[85.2 Lacs (Individual Cover) - Rs. 2,850/- (CJ Rs. 10 Lacs (Family Floater) — Rs. "28 300/-
[J Rs. 2 Lacs (Family Floater) -Rs. 11,750/-
[J Rs.5 Lacs (Family Floater) -Rs. 14,500/- (Premium includes 14.5% Service Tax)
‘sil famty members slo have tel personal I 10 (16 cg then please mention below j
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Dependent Children upto 25 years of age
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Sam insured ef Personal Acdent plc is € V0 Lacs, €5 Lacs oF C2 Lacs
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| Relation: Date of Birth:
i + Demand Ort / Pay Orde shouldbe made n favor of
“IRIMINTERNATIONAL ORGANISATION A/c Shravak Arogyam”Payable AT PAR or AT MUMBA
cain renga NEF wi ret be acepte {Premium canalbobe pid ONE plete va ou mebate wont
Bank Nome, Branch Name.
Demand Orat/ Pay Order no: Amount: Dated
FIEREEEIEEY have read and understood the terms & conditions reitedo the Phase ¢ mec
Scheme | abi to folow them and accept all he changes / modifications / amenixner et
I theres aed conditions of the scheme. alo hereby confi tht allthe details mentioned by me ae
f correct and to the best of my knowledge, in all matters the decision of JO wil Be final
T For more details please visit website httpy//www.jio.net.in
‘ain Intemational Organisation = 10's other SUPPORTING & CONNECTED Associations:
Al Shemale Shika Members fa fur Sats, Active Volunteers ofan Sangh & Sama rom Al ver Ina Mahia Mond! & Yirak Mand,
‘Yak Mahasangh Jin CA Federation XAR, Jin Advocate Federation JAP, Jin interational Were Organsatclon NWO) Ji Intemational Yeuth Organon UO)
[os Meds tava edocs ines ompatons and my ce Osun cat bes / Presa / ca serves
** J1O has the Right to TERMINATE (Reject) this application, if any details provided are inappropriate.
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