Relation to policyholder	Salutation	Full Name	Gender	Marital Status	Date of Birth	Sum Insured	Are you currently suffering from fever and body rash or been diagnosed with dengue
	Select	Select		Select	Select			Yes No
	Select	Select		Select	Select			Yes No
	Select	Select		Select	Select			Yes No
	Select	Select		Select	Select			Yes No
	Select	Select		Select	Select			Yes No
	Select	Select		Select	Select			Yes No
	Total premium in Rs. ( excluding  service tax & applicable cess)
	Gross premium in Rs. ( including  service tax & applicable cess)