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Gender Male

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Gender female

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Gender x

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First Name(Required)

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Last Name(Required)

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DD/MM/YYY(Required)

DD slash MM slash YYYY

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Age(Required)

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Gender(Required)

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Mobile Number(Required)

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Email(Required)

Who do you want to be
Covered Under the SHIELD?

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Who do you want to be covered under the shield?(Required)

Myself

Me & My Family

Others

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Myself

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Me & My Family

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Others

Hello

Thanks for your interest, we will catch up with you over a phone call and help you get the right insurance for your loved ones.

Great Job!

Words cannot express how grateful we are for your
willingness to volunteer

Thank you!

You now have the option to swiftly navigate to the Health Declaration
form or continue onward with Inshu Charity.