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Location
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Head of Family
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Spouse
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Parents
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Children
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SUVARNA KARNATAKA ABHIYAAN 2024 – INSURANCE ENROLLMENT FORM

*Team Reference

*Date of Collection

*Ward Name(Select from the list)

*House No

*Name of the Person(Information provider)

*Number of Members

Type of House

Own House

Rented House

*Are you a permanent resident (born and brought up) in Marasur Gram Panchayat?

Yes

If No, mention your Permanent Address(Enter Address with Pincode as in Aadhaar)

Current Address (Enter Address with Pincode as in Aadhaar)

SUVARNA KARNATAKA ABHIYAAN 2024

DETAILS OF THE HEAD OF THE FAMILY

*Head of the Family – Name

*Marital Status

*Gender

Mobile Number

*Date of Birth(as per Aadhaar/ Age proof document)

Age

*Education

Education, If Other or PG please specify

Employment Details. Are you currently

If Employed, what is your main occupation

If Self Employed, select

Are you having an account with any of the following banks

Post Office

SBI

Yes Bank

CNRB

HDFC Bank

Corporation Bank

UBI

BOB

Andhra Bank

Axis Bank

Karur Vysya Bank

Other

PSC Bank or Post office Account Type

SB/ CA

FD/CC

Loan

Bank/Post office account number

Bank Name

Bank Branch

Is your Aadhar card linked with your bank account?

Yes

Dont Know

Are you physically challenged?

If Yes, Specify

Do you have any Personal Life insurance policy?

If Yes, Personal Life insurance is with

Do you have any Personal Health insurance policy?

If Yes, Personal Health insurance is with

Do you have a Pension Plan policy?

If Yes, Pension Plan is with

Are you aware of any government insurance schemes?

If yes, how did you become aware of the same?

Do you have any of the following insurance schemes of the government ?

PMSBY

PMJJBY

PMFBY

Ayushman Bharat Arogya Karnataka

Others

SUVARNA KARNATAKA ABHIYAAN 2024

DETAILS OF SPOUSE

Spouse Name

Gender

Date of Birth(as per Aadhaar/ Age proof document)

Age

Education

Education, If Other or PG please specify

Employment Details. Are you currently

If Employed, what is your main occupation

If Self Employed, select

Are you having an account with any of the following banks

Post Office

SBI

Yes Bank

CNRB

HDFC Bank

Corporation Bank

UBI

BOB

Andhra Bank

Axis Bank

Karur Vysya Bank

Other

PSC Bank or Post office Account Type

SB/ CA

FD/CC

Loan

Bank/Post office account number

Bank Name

Bank Branch

Is your Aadhar card linked with your bank account?

Yes

Dont Know

Are you physically challenged?

If Yes, Specify

Do you have any Personal Life insurance policy?

If Yes, Personal Life insurance is with

Do you have any Personal Health insurance policy?

If Yes, Personal Health insurance is with

Do you have a Pension Plan policy?

If Yes, Pension Plan is with

Are you aware of any government insurance schemes?

If yes, how did you become aware of the same?

Do you have any of the following insurance schemes of the government ?

PMSBY

PMJJBY

PMFBY

Ayushman Bharat Arogya Karnataka

Others

SUVARNA KARNATAKA ABHIYAAN 2024

Please fill in the details of Parents and Parent in laws aged below 71 yrs

PARENT – FATHER

*Is the Father of the Head of the Family alive and staying in this house?

Yes

Fathers Name

Date of Birth(as per Aadhaar/ Age proof document)

Age

Education

Education, If Other or PG please specify

Employment Details. Are you currently

If Employed, what is your main occupation

If Self Employed, select

Are you having an account with any of the following banks

Post Office

SBI

Yes Bank

CNRB

HDFC Bank

Corporation Bank

UBI

BOB

Andhra Bank

Axis Bank

Karur Vysya Bank

Other

PSC Bank or Post office Account Type

SB/ CA

FD/CC

Loan

Bank/Post office account number

Bank Name

Bank Branch

Is your Aadhar card linked with your bank account?

Yes

Dont Know

Are you physically challenged?

If Yes, Specify

Do you have any Personal Life insurance policy?

If Yes, Personal Life insurance is with

Do you have any Personal Health insurance policy?

If Yes, Personal Health insurance is with

Do you have a Pension Plan policy?

If Yes, Pension Plan is with

Are you aware of any government insurance schemes?

If yes, how did you become aware of the same?

Do you have any of the following insurance schemes of the government ?

PMSBY

PMJJBY

PMFBY

Ayushman Bharat Arogya Karnataka

Others

PARENT – MOTHER

*Is the Mother of the Head of the Family alive and staying in this house?

Yes

Mothers Name

Date of Birth(as per Aadhaar/ Age proof document)

Age

Education

Education, If Other or PG please specify

Employment Details. Are you currently

If Employed, what is your main occupation

If Self Employed, select

Are you having an account with any of the following banks

Post Office

SBI

Yes Bank

CNRB

HDFC Bank

Corporation Bank

UBI

BOB

Andhra Bank

Axis Bank

Karur Vysya Bank

Other

PSC Bank or Post office Account Type

SB/ CA

FD/CC

Loan

Bank/Post office account number

Bank Name

Bank Branch

Is your Aadhar card linked with your bank account?

Yes

Dont Know

Are you physically challenged?

If Yes, Specify

Do you have any Personal Life insurance policy?

If Yes, Personal Life insurance is with

Do you have any Personal Health insurance policy?

If Yes, Personal Health insurance is with

Do you have a Pension Plan policy?

If Yes, Pension Plan is with

Are you aware of any government insurance schemes?

If yes, how did you become aware of the same?

Do you have any of the following insurance schemes of the government ?

PMSBY

PMJJBY

PMFBY

Ayushman Bharat Arogya Karnataka

Others

PARENT – FATHER IN LAW

Is the Father in Law of the Head of the Family alive and staying in this house?

Yes

Father in Law Name

Date of Birth(as per Aadhaar/ Age proof document)

Age

Education

Education, If Other or PG please specify

Employment Details. Are you currently

If Employed, what is your main occupation

If Self Employed, select

Are you having an account with any of the following banks

Post Office

SBI

Yes Bank

CNRB

HDFC Bank

Corporation Bank

UBI

BOB

Andhra Bank

Axis Bank

Karur Vysya Bank

Other

PSC Bank or Post office Account Type

SB/ CA

FD/CC

Loan

Bank/Post office account number

Bank Name

Bank Branch

Is your Aadhar card linked with your bank account?

Yes

Dont Know

Are you physically challenged?

If Yes, Specify

Do you have any Personal Life insurance policy?

If Yes, Personal Life insurance is with

Do you have any Personal Health insurance policy?

If Yes, Personal Health insurance is with

Do you have a Pension Plan policy?

If Yes, Pension Plan is with

Are you aware of any government insurance schemes?

If yes, how did you become aware of the same?

Do you have any of the following insurance schemes of the government ?

PMSBY

PMJJBY

PMFBY

Ayushman Bharat Arogya Karnataka

Others

PARENT – MOTHER IN LAW

Is the Mother in Law of the Head of the Family alive and staying in this house?

Yes

Mother in Law Name

Date of Birth(as per Aadhaar/ Age proof document)

Age

Education

Education, If Other or PG please specify

Employment Details. Are you currently

If Employed, what is your main occupation

If Self Employed, select

Are you having an account with any of the following banks

Post Office

SBI

Yes Bank

CNRB

HDFC Bank

Corporation Bank

UBI

BOB

Andhra Bank

Axis Bank

Karur Vysya Bank

Other

PSC Bank or Post office Account Type

SB/ CA

FD/CC

Loan

Bank/Post office account number

Bank Name

Bank Branch

Is your Aadhar card linked with your bank account?

Yes

Dont Know

Are you physically challenged?

If Yes, Specify

Do you have any Personal Life insurance policy?

If Yes, Personal Life insurance is with

Do you have any Personal Health insurance policy?

If Yes, Personal Health insurance is with

Do you have a Pension Plan policy?

If Yes, Pension Plan is with

Are you aware of any government insurance schemes?

If yes, how did you become aware of the same?

Do you have any of the following insurance schemes of the government ?

PMSBY

PMJJBY

PMFBY

Ayushman Bharat Arogya Karnataka

Others

SUVARNA KARNATAKA ABHIYAAN 2024

Please fill in the details of Unmarried Children residing in the same house age above 18 years

1st CHILD DETAILS

*Do you have any Unmarried Children?

Yes

1st Child Name

Gender

Date of Birth(as per Aadhaar/ Age proof document)

Age

Education

Education, If Other or PG please specify

Employment Details. Are you currently

If Employed, what is your main occupation

If Self Employed, select

Are you having an account with any of the following banks

Post Office

SBI

Yes Bank

CNRB

HDFC Bank

Corporation Bank

UBI

BOB

Andhra Bank

Axis Bank

Karur Vysya Bank

Other

PSC Bank or Post office Account Type

SB/ CA

FD/CC

Loan

Bank/Post office account number

Bank Name

Bank Branch

Is your Aadhar card linked with your bank account?

Yes

Dont Know

Are you physically challenged?

If Yes, Specify

Do you have any Personal Life insurance policy?

If Yes, Personal Life insurance is with

Do you have any Personal Health insurance policy?

If Yes, Personal Health insurance is with

Do you have a Pension Plan policy?

If Yes, Pension Plan is with

Are you aware of any government insurance schemes?

If yes, how did you become aware of the same?

Do you have any of the following insurance schemes of the government ?

PMSBY

PMJJBY

PMFBY

Ayushman Bharat Arogya Karnataka

Others

2nd CHILD DETAILS

Do you have an unmarried Second child and staying in this house?

Yes

2nd Child Name

Gender

Date of Birth(as per Aadhaar/ Age proof document)

Age

Education

Education, If Other or PG please specify

Employment Details. Are you currently

If Employed, what is your main occupation

If Self Employed, select

Are you having an account with any of the following banks

Post Office

SBI

Yes Bank

CNRB

HDFC Bank

Corporation Bank

UBI

BOB

Andhra Bank

Axis Bank

Karur Vysya Bank

Other

PSC Bank or Post office Account Type

SB/ CA

FD/CC

Loan

Bank/Post office account number

Bank Name

Bank Branch

Is your Aadhar card linked with your bank account?

Yes

Dont Know

Are you physically challenged?

If Yes, Specify

Do you have any Personal Life insurance policy?

If Yes, Personal Life insurance is with

Do you have any Personal Health insurance policy?

If Yes, Personal Health insurance is with

Do you have a Pension Plan policy?

If Yes, Pension Plan is with

Are you aware of any government insurance schemes?

If yes, how did you become aware of the same?

Do you have any of the following insurance schemes of the government ?

PMSBY

PMJJBY

PMFBY

Ayushman Bharat Arogya Karnataka

Others

3rd CHILD DETAILS

Do you have an unmarried Third child and staying in this house?

Yes

3rd Child Name

Gender

Date of Birth(as per Aadhaar/ Age proof document)

Age

Education

Education, If Other or PG please specify

Employment Details. Are you currently

If Employed, what is your main occupation

If Self Employed, select

Are you having an account with any of the following banks

Post Office

SBI

Yes Bank

CNRB

HDFC Bank

Corporation Bank

UBI

BOB

Andhra Bank

Axis Bank

Karur Vysya Bank

Other

PSC Bank or Post office Account Type

SB/ CA

FD/CC

Loan

Bank/Post office account number

Bank Name

Bank Branch

Is your Aadhar card linked with your bank account?

Yes

Dont Know

Are you physically challenged?

If Yes, Specify

Do you have any Personal Life insurance policy?

If Yes, Personal Life insurance is with

Do you have any Personal Health insurance policy?

If Yes, Personal Health insurance is with

Do you have a Pension Plan policy?

If Yes, Pension Plan is with

Are you aware of any government insurance schemes?

If yes, how did you become aware of the same?

Do you have any of the following insurance schemes of the government ?

PMSBY

PMJJBY

PMFBY

Ayushman Bharat Arogya Karnataka

Others

4th CHILD DETAILS

Do you have an unmarried Fourth child and staying in this house?

Yes

4th Child Name

Gender

Date of Birth(as per Aadhaar/ Age proof document)

Age

Education

Education, If Other or PG please specify

Employment Details. Are you currently

If Employed, what is your main occupation

If Self Employed, select

Are you having an account with any of the following banks

Post Office

SBI

Yes Bank

CNRB

HDFC Bank

Corporation Bank

UBI

BOB

Andhra Bank

Axis Bank

Karur Vysya Bank

Other

PSC Bank or Post office Account Type

SB/ CA

FD/CC

Loan

Bank/Post office account number

Bank Name

Bank Branch

Is your Aadhar card linked with your bank account?

Yes

Dont Know

Are you physically challenged?

If Yes, Specify

Do you have any Personal Life insurance policy?

If Yes, Personal Life insurance is with

Do you have any Personal Health insurance policy?

If Yes, Personal Health insurance is with

Do you have a Pension Plan policy?

If Yes, Pension Plan is with

Are you aware of any government insurance schemes?

If yes, how did you become aware of the same?

Do you have any of the following insurance schemes of the government ?

PMSBY

PMJJBY

PMFBY

Ayushman Bharat Arogya Karnataka

Others

5th CHILD DETAILS

Do you have an unmarried Fifth child and staying in this house?

Yes

5th Child Name

Gender

Date of Birth(as per Aadhaar/ Age proof document)

Age

Education

Education, If Other or PG please specify

Employment Details. Are you currently

If Employed, what is your main occupation

If Self Employed, select

Are you having an account with any of the following banks

Post Office

SBI

Yes Bank

CNRB

HDFC Bank

Corporation Bank

UBI

BOB

Andhra Bank

Axis Bank

Karur Vysya Bank

Other

PSC Bank or Post office Account Type

SB/ CA

FD/CC

Loan

Bank/Post office account number

Bank Name

Bank Branch

Is your Aadhar card linked with your bank account?

Yes

Dont Know

Are you physically challenged?

If Yes, Specify

Do you have any Personal Life insurance policy?

If Yes, Personal Life insurance is with

Do you have any Personal Health insurance policy?

If Yes, Personal Health insurance is with

Do you have a Pension Plan policy?

If Yes, Pension Plan is with

Are you aware of any government insurance schemes?

If yes, how did you become aware of the same?

Do you have any of the following insurance schemes of the government ?

PMSBY

PMJJBY

PMFBY

Ayushman Bharat Arogya Karnataka

Others

SUVARNA KARNATAKA ABHIYAAN 2024

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.