Member Registration form

Registration Form

Insured Type * Name of Doctor / Medical Establishment * Residence Address *

Hospital / Clinic Address *

Mobile Number *

Email * ID Proof * ID Number * Insurance Cover Required * Please give 2 references of Doctors to whom you would recommend our services *

Doctor's Name	Contact Number	Location

Doctor's Representative Name * Email of Doctor's Representative * Total Amount Paid * Mode of Payment and Cheque / Ref. No. * Upload Registration Certificate *

Declaration *

I agree and hereby declare that the above statement and particulars are true and correct.

Upload Signature *

Place of Submission * Motor Insurance Expiry Date * Health Insurance Expiry Date *