PRAVASI SURAKSHA / KUDUMBA AROGYA SCHEME
Please read instructions carefully before filling this form; fill in all respects and send to the address given above with the DD or Cheque drawn in favour of "THE NEW INDIA ASSURANCE CO., LTD". Photocopy of this form if available, can also be used. Credit card holders can fill up the information online and provide the credit card details at the end of the form.

1. Name of the Non Resident Indian (in Capitals)

Name

2. Passport Number with alphabetic prefix :  

3. Sex :   M F 

4. Permanent Residential Address in India :

Street Address
Address (cont.)
City
State/Province
Zip/Postal code
Country

5. Address to which certificate is to be sent (India or abroad) :

Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country

6. Name and address of employer abroad :

Name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country

7. If the NRI is already a member of the PRAVASI SURAKSHA SCHEME, please give enrolment number and office of issue :

  Certificate Number :   Issuing office :

8. Details of persons joining the scheme (NRI and family members should join the same scheme. Atleast NRI must join PS-I or PS-II.

  8a.  PRAVASI SURAKSHA PS-I or PS-II                                                                                      

Sl.no & Relationship Name of persons to   be insured Sex M/F Age Name of Nominee & Relationship Scheme PS-I Scheme PS-II
1. NRI 990/- 1600/-
2. Spouse 650/990* 990/1600*
3. 1st Child 500 650
4. 2nd Child 500 650
5. 3rd Child 500 650
Total
Less 10 % discount if more than one person covered
Net amount [ 8(a) ] I.Rs. I.Rs.

                                                                                                                                                       

* If spouse is also employed abroad both can opt for the same sum insured.     

       

  8b. Persons to be covered under KUDUMBA AROGYA SCHEME (KA-I or KA-II)

Sl.No Name Relationship Sex M/F Age Date of Birth Scheme KA-I Rs.1,00,000 Scheme KA-II Rs.2,00,000
1. NRI-SELF 1500/- 2925/-
2. 2nd member 450/- 875/-
3. 3rd member 300/- 590/-
4. 4th member 250/- 490/-
5. 250/- 490/-
6. Father 650/- 1270/-
7. Mother 650/- 1270/-
          Total 8 (b)

Parents should be below 70 years of age.                                                              Total 8a + 8b = Rs.:                                                  

       

  8c. PRAVASI VANITHA SURAKSHA SCHEME ( for employed NRI ladies only )

Enrollment in PS is compulsory for the person who joins Pravasi Vanitha Suraksha Scheme.

 8c(i).    If If joining Vanitha Suraksha Scheme tick 'Yes'

Yes/No          (8c) - Dhs. 75 / -

            Any information given above about the person joining Pravasi Vanitha Suraksha need not be repeated.

8(a) + 8(b) + 8(c) = Dhs.
Total                  = Dhs.
8c(ii).    Name of NRI Woman (employed abroad)
8c(iii).   Passport No. 
8c(iv).   Name & address of employer abroad
8c(v).    Do you have any disease/illness at present?
            If so, give details.
8c(vi).   Details of ornaments usually worn?
8c(vii).  Ornaments worn on special occasions?  

 

Note : The prices are in Indian Rupees  convertible into UAE Dirhams or US Dollars at the current rate of exchange.

9. Name & Age of children:     Not Applicable (Only if all children are not covered under 8(a) or 8(b)

   SONS 

    (i)   

    (ii)  

    (iii) 

   DAUGHTERS

    (i)   

    (ii)  

    (iii) 

10. Person in whose name payments under Kudumba Arogya Scheme to be made :

Name

11a. Do you/any of the persons to be insured suffer at present from any diseases/illness or injury ? if yes state details

Yes No

Details of illness/injury/accident :


11b. Is any of the persons to be insured in this scheme under medication for any ailments like diabetes, blood pressure, heart ailments etc. ? if so, give details

Yes No

Details of medication for ailments like diabetes, blood pressure, heart ailments etc


12a.Have you/any persons to be insured undergone any treatment during the past two years ? if yes, give details like name of diseases, hospital, period of treatment etc.,

Yes No

Details of previous treatments undergone in the past like name of the diseases, hospital, period of treatment etc.,


12b. Was it completely cured ? If not, present condition

Yes No

If not cured completely, then give the present condition


13. Name of the applicant and relationship (if applicant is not the NRI) :

Name

 

14. The district in Kerala in which you want the claims to be serviced :


15. Details of payment mode :

Note : The above Form can be printed/completed and mailed to the NIA Co. Ltd., P.O. Box 5701, Dubai, UAE /NIA Co. Ltd. P.O Box 53842 Riyadh - 11593/ NIA Co. Ltd. P.O Box 41051 Jeddah/ NIA Co. Ltd. P.O Box 3860 Al-Khobar-31952   along with the Demand Draft of the relevant amount. Alternatively the Form can be mailed to us while simultaneously remittance in US dollar at the current rate of exchange can be made to New India's account no. 020-150520-001 with HSBC, Dubai, UAE. Copy of the Bank     Tranfer / Advice to be faxed to us.

Cheque no/DD no.   dated 
Credit card  
Cardholder name
Card number Expiration Date :
Credit card should have minimum one month's validity.         (Enter in dd/mm/yyyy format only)

 
Signature  :