Employee and dependent details for ICICI Lombard Group insurance

Sum Insured: 5 lakh

Monthly premium between INR 950/- (min) to INR 1400/- (max) per month (ideally close the lower range)

*more details shared upon confirmation

Name *

Email *

Mobile Number *

Date of birth *

Number of dependents to include *

Details of Dependent 1: *

Please provide the name, relation and date of birth of the dependant in the given format (Clint Eastwood - Father - 31 May 1940)

Details of Dependent 2: *

Please provide the name, relation and date of birth of the dependant in the given format (Dina Eastwood - Mother - 11 July 1955)

Details of Dependent 3: *

Please provide the name, relation and date of birth of the dependant in the given format (Alison Eastwood - Wife - 22 May 1972)

Details of Dependent 4: *

Please provide the name, relation and date of birth of the dependant in the given format (Morgan Eastwood - Daughter - 12 December 1996)

Details of Dependent 5: *

Please provide the name, relation and date of birth of the dependant in the given format (Kyle Eastwood - Son - 17 March 1994)

Any queries? *

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