KONBIR 2025 – INSURANCE ENROLLMENT FORM

*Team Reference

*Date of Collection

*Village Name(Select from the List)

FAMILY INSURANCE DETAILS

*Respondent Name

*Full Name of the Head of the Family

*Address (as per Government ID)

*Are you a Permanent Resident of Konbir Gram Panchayat

Yes

No

*No. of Members Employed

i. Government

ii. Private

iii. Other

*Total Number of members in the family

*Number of family members aged between 18-70

*Number of Eligible Family members (aged 18-70) Currently insured (Life/Health/Accident)

*Number of Eligible Family members (aged 18-70) NOT insured currently

*Have you filled the Google Form for Uninsured Members

Yes

No

*How many consent forms are submitted ?

*Other Details

Please confirm correct information is entered before submission.

The information collection is complete and ready for submission. Once submitted, it cannot be edited and only re-entered.