Synck || Your Wellness Expert ||

Synck || Your Wellness Expert ||

SYNCK SALES PORTAL

PRODUCT

Retail OPD products by Synck

PARTNERCODE

Source Input

VARIANT

COVERAGE

Self

Family

Self (Primary Proposer)

Personal Information

Full Name of Primary Insured

Gender

Male Female Other

Date of Birth

Marital Status

Occupation

Contact Number

Email Address

Residential Address

Street

City

State

Postal Code

Nationality

Policy Details

Type of Policy
Individual Family Floater Critical Illness Top-Up Plan

Policy Duration
1 Year 2 Years 3 Years

Health Conditions (if any)

Nominee Details

Full Name of Nominee

Relationship to Primary Insured

Nominee’s Date of Birth

Nominee’s Contact Number

Nominee’s Address

Street

City

State

Postal Code

Nominee’s ID Proof

Dependents 1 Details

Dependent Name

Relationship to Insured

Date of Birth

Gender
Male Female Other

Occupation

Health Conditions (If any)

Dependents 2 Details

Dependent Name

Relationship to Insured

Date of Birth

Gender
Male Female Other

Occupation

Health Conditions (If any)

Dependents 3 Details

Dependent Name

Relationship to Insured

Date of Birth

Gender
Male Female Other

Occupation

Health Conditions (If any)

Payment Information

Premium Payment Mode
Annual Subscription

Preferred Payment Method
Credit Card Debit Card

Bank Name & Branch (if paying via Bank Transfer)

Policy Premium Amount

Payment Reference Number (if applicable)

Declaration

I, the undersigned, hereby declare that the information provided in this form is true and complete to the best of my knowledge. I agree to the terms and conditions of the health insurance policy and consent to the processing of my personal and medical details as per the privacy policy.

Signature

Date

Date and Time