BCHInsuranceLink - HDFC Ergo

Bank Details

Are You Assisted with HDFC Bank Employee*

Yes NO

LG code

Dukaandar Suraksha Cover Details
Cover details	Plan A	Plan B	Plan C	Plan D
Fire, Burglary (for shop’s content)	5,00,000	10,00,000	20,00,000	50,00,000
Cash in Transit	25,000	50,000	1,00,000	2,50,000
Cash in Safe	25,000	50,000	1,00,000	2,50,000
Electronic Equipment Insurance	50,000	1,00,000	2,00,000	2,50,000
Hospital Cash: Accident Only (Amount Payable per Day for up to 30 days)	1,000	1,500	2,000	5,000
Hospital Cash: Illness Only (Amount Payable per Day for up to 30 days)	1,000	1,500	2,000	5,000
Premium With Tax	3785	7341	14681	28185

Customer Details

Customer ID *

Policy Tenure *

Plan Variant *

Premium *

Customer Type*

Salutation *

Business Name *

Insured First Name *

Insured Last Name *

Insured DOB *

Email ID *

Registered Mobile Number *

Insured Height(in cm) *

Insured Weight(in kg) *

Nominee name *

Nominee Relationship *

Nominee DOB *

Communication Address Line 1 *

Communication Address Line 2 *

Communication Address Pincode *

Communication City *

Communication State *

Risk Address Same as Communication Address. *

Risk Address Line 1 *

Risk Address Line 2 *

Risk Address Pincode *

Risk City *

Risk State *

GSTIN Number

Occupation *

Source of income *

Annual Income *

Auto-Renewal

I hereby declare that customer is Business Cardholder of HDFC Bank*

Does any of the members proposed to be insured suffer from Diabetes, Hypertension, Thyroid Disorder, Nervous disorder, fits, mental condition, Heart & Circulatory disorders, Respiratory disorder, Disorders of the stomach including intestine, Kidney including kidney stones, Prostate disorder, Disorder of Spine and Joints, Tumours or Cancer, ever reported positive for Hepatitis B, HIV / AIDS or other sexually transmitted disease or is pregnant at the time of application.	Yes	No
Does any of the members proposed to be insured suffer from any pre-existing disease ?Please choose "Yes" in case any of the proposed person to be insured has been/are under any continuous medication for treatment for any illness (Excluding vitamins, supplements) or under treatment for any illness.	Yes	No

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Bank Details

Bank Employee code *

Branch Location *

Campaign Code *

Renewal info

Previous Plan Type *

Previous Premium *

Plan Variant *

Premium *

Customer / Institution Name *

Shop- Policy Cover *

Salutation *

Insured First Name *

Insured Last Name *

Nominee name *

Nominee Relationship *

Risk Address Line 1 *

Risk Address Line 2 *

Risk Address Pincode *

Risk City *

Risk State *

Source *

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