Insured Person's Details

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Selected Plan Guardian Health Shield Plus Guardian Life

Premium ৳4,250/year Coverage: ৳1,00,000

Insured Person's Details

1

Your Information(Primary Insured)

2

Spouse Information(Secondary Insured)

3

Nominee Information(must be above 18 years of age)

4

Declaration

Your Name *

Date of Birth *

Gender *

Male Female

Identification Type *

Document Number *

Mobile Number *

Spouse Name *

Date of Birth *

Gender *

Male Female

Identification Type *

Document Number *

Mobile Number *

Nominee Name *

Date of Birth *

Relationship *

Identification Type *

Document Number *

Mobile Number *

I hereby declare that the information provided above is true and correct to the best of my knowledge.

I understand that any false or misleading information may result in the cancellation of my insurance policy.

I agree to the terms and conditions of the insurance policy as outlined by the insurance provider.

I agree to the above declaration and the Terms & Conditions.