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E filled in by Bank) 3(a) Branch Name/City: (b) BIC Code : 2. Mobile No: SUM INSURED PER FAMILY (please tick) Rs Lacs 0.50 1.00 1.50 2.00 2.50 Rs Lacs 3.00 3.50 4.00 4.50 5.00 FRESH PROPOSAL / RENEWAL PROPOSAL(Please tick) (Attach copy of existing Mahabank Swasthya Yojna Policy in case of renewal) (Attach copy of any other medical insurance held, if any) 5 (c)IFS Code (d ) Proposal From: Rural/Urban/Semi-Urban 4. Account No. SB/CA/FD/Others (please specify) Date of Credit to United Indi.

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