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Ed by the Bank) 1.NAME & ADDRESS OF THE ACCOUNT HOLDER (in CAPITAL letters) 3 a. Branch Name b. DP Code b. City 2. SUM INSURED PER FAMILY Please ( ) : Rs.50,000 Rs.1 Lac Rs.1.5 Lac Rs.3 Lac Rs.3.5 Lac Rs.4 Lac Rs.2 Lac Rs.2.5 Lac Rs.4.5 Lac Rs.5 Lac c. Proposal from (Pl. Tick) Rural/Semi Urban/Urban 4. Account No . SB/CA/FD/others (Pl. specify) 5. DETAILS OF PERSONS TO BE COVERED : SLNO NAME OF THE INSURED PERSON (in CAPITAL letters) AGE (yrs) SEX RELATIONS.

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