The Application Form is successfully submitted.In case of any errors or any data not collected, please contact the insurance coordinator. Also please reconcile the entry with the daily report.
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SURAKSHA REKHA 2024 - INSURANCE ENROLLMENT FORM
*Team Reference
--- Select ---
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*Date of Collection
*Ward Name
(Select from the list)
--- Select ---
KANNAPPANKUNDU
MATTIKKUNNU
VALLIYAD
MUPPATHEKKAR
KANALATT
ADIVARAM
ALIKKAD
KAITHAPOTIL
WEST KAITHAPOYIL
ODUGAKKAD
KUPPAYAKODE
MAMMUNNIPPADI
KOTTARAKOTH
KAVUM PURAM
PERUMBALLY
MALAPURAM
ELOKKARA
EANGAPUZHA
VANIKKARA
KARIKULAM
KAKKAVAYAL
*House No
*Name of the Person
(Information provider)
*No of Members
*Address
(Enter Address with Pincode as in Aadhaar)
Annual Income as per Ration Card
Ration Card Type
.
APL
.
BPL
.
Nil
*Is there any earning members in your family residing outside the state?
.
No
.
Yes
If yes, mention the number of persons residing in
Outside Kerala within India
Middle East
Europe
Canada
Australia
New Zealand
United States of America
United Kingdom
Others
*Is there any members in your family pursuing education outside the state?
.
No
.
Yes
If yes, mention the number of persons studying in
Outside Kerala within India
Middle East
Europe
Canada
Australia
New Zealand
United States of America
United Kingdom
Others
Back
Next
Demographic Details
*Religion
--- Select ---
Hindu
Christian
Muslim
Others
Prefer not to say
No Religion
*Social Class
--- Select ---
General Category (GC)
Scheduled Caste (SC)
Scheduled Tribe (ST)
OBC
Others
Prefer not to say
*Area of Living
--- Select ---
Tribal Area
Hilly Area
Plain Area
Remote Area
*Type of House
--- Select ---
Own House
Rented House
House on Govt Land
Temporary Shelter
Others
*House - Wall Type
--- Select ---
Cement / RBC / RCC
Burnt brick /Stone/ Limestone
Mud (with / without bamboo) /Unburnt brick
Canvas / cloth
Other katcha
Timber
Iron or other metal sheet
Other
Refuse to answer
*House - Roof Type
--- Select ---
Cement / RBC / RCC
Tiles / slate
Mud / unburnt brick
canvas / cloth
Other katcha
Burnt brick / stone / limestone
Iron / zinc /other metal Sheet /Asbestos Sheet
Other
Refuse to answer
If own house, do you have insurance for the house?
--- Select ---
No
Yes
If yes, is the house insured with
--- Select ---
Public Sector
Private Sector
*Do you have Electricity supply
--- Select ---
No
Yes
If yes, is the electricity metered ?
--- Select ---
Yes
No
*Is toilet facility available ?
--- Select ---
No
Yes
Back
Next
DETAILS OF THE HEAD OF THE FAMILY
*Head of the Family - Name
*Gender
--- Select ---
Male
Female
3rd Gender
*Marital Status
--- Select ---
Married
Unmarried
Divorcee
*Mobile Number
*Date of Birth
Age
Email ID
*Education
--- Select ---
No Schooling
1 - 4th Std
5th - 9th Std
SSLC/HSE
UG / +2
Graduate
Diploma
Post Graduate
Dont know
Refused to answer
*Employment Details. Are you currently
--- Select ---
Employed
Self Employed
Unemployed
Housewife
Retired
Student
Refuse to answer
If Employed, what is your main occupation
--- Select ---
Daily Wage Labourer
Govt Employee
Private Sector
Cooperative Sector
Driver
Legislative/Law enforcement workers
Armed forces
Others
If Self Employed, select
--- Select ---
Trader/ Agent
Agriculturist
Own Taxi
Businessman-0 employees
Businessman-1-9 employees
Businessman-10+ employees
Others
*Bank Membership Details
--- Select ---
A - Class
C - Class
D - Class
No Membership
Dont Know
Member Class - Prefer not to say
PSC Bank Account Type
.
SB/CA
.
FD/CC
.
Loan
*Do you have any Physical Deformity ?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Specify the deformity
Do you have any Personal Life insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Personal Life insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Pension Plan policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Pension Plan is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Personal Health Insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Health Insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Govt Plan
Are you aware of any government insurance schemes?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If yes, how did you become aware of the same
--- Select ---
Ward Officials
Advertisements
Family
Friends
Others
Do you have any of the following insurance schemes of the government?
.
PMSBY
.
PMJJBY
.
KASP
.
Ayushman Bharat/ RSBY
.
Others
Are you having an account with any of the following banks
.
SBI
.
SIB
.
CNRB
.
FB
.
KGB
.
KB
.
ICICI
.
HDFC
.
UBI
.
BOB
.
IOB
.
PNB
.
Other
Is your Aadhar card linked with your bank account?
--- Select ---
No
Yes
Dont know
Back
Next
DETAILS OF SPOUSE
Spouse Name
Gender
--- Select ---
Male
Female
3rd Gender
Date of Birth
Age
Education
--- Select ---
No Schooling
1 - 4th Std
5th - 9th Std
SSLC/HSE
UG / +2
Graduate
Diploma
Post Graduate
Dont know
Refused to answer
Employment Details. Are you currently
--- Select ---
Employed
Self Employed
Unemployed
Housewife
Retired
Student
Refuse to answer
If Employed, what is your main occupation
--- Select ---
Daily Wage Labourer
Govt Employee
Private Sector
Cooperative Sector
Driver
Legislative/Law enforcement workers
Armed forces
Others
If Self Employed, select
--- Select ---
Trader/ Agent
Agriculturist
Own Taxi
Businessman-0 employees
Businessman-1-9 employees
Businessman-10+ employees
Others
Bank Membership Details
--- Select ---
A - Class
C - Class
D - Class
No Membership
Dont Know
Member Class - Prefer not to say
PSC Bank Account Type
.
SB/CA
.
FD/CC
.
Loan
Do you have any physical Deformity?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Specify
Do you have any Personal Life insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Personal Life insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Pension Plan policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Pension Plan is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Personal Health Insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Health Insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Govt Plan
Are you aware of any government insurance schemes?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If yes, how did you become aware of the same
--- Select ---
Ward Officials
Advertisements
Family
Friends
Others
Do you have any of the following insurance schemes of the government?
.
PMSBY
.
PMJJBY
.
KASP
.
Ayushman Bharat/ RSBY
.
Others
Are you having an account with any of the following banks
.
SBI
.
SIB
.
CNRB
.
FB
.
KGB
.
KB
.
ICICI
.
HDFC
.
UBI
.
BOB
.
IOB
.
PNB
.
Other
Is your Aadhar card linked with your bank account?
--- Select ---
No
Yes
Dont know
Back
Next
Please fill in the details of Parents and Parent in laws
PARENT - FATHER
Is the Father of the Head of the Family alive and staying in this house ?
.
Yes
.
No
Fathers Name
Date of Birth
Age
Education
--- Select ---
No Schooling
1 - 4th Std
5th - 9th Std
SSLC/HSE
UG / +2
Graduate
Diploma
Post Graduate
Dont know
Refused to answer
Employment Details. Are you currently
--- Select ---
Employed
Self Employed
Unemployed
Housewife
Retired
Student
Refuse to answer
If Employed, what is your main occupation
--- Select ---
Daily Wage Labourer
Govt Employee
Private Sector
Cooperative Sector
Driver
Legislative/Law enforcement workers
Armed forces
Others
If Self Employed, select
--- Select ---
Trader/ Agent
Agriculturist
Own Taxi
Businessman-0 employees
Businessman-1-9 employees
Businessman-10+ employees
Others
Bank Membership Details
--- Select ---
A - Class
C - Class
D - Class
No Membership
Dont Know
Member Class - Prefer not to say
PSC Bank Account Type
.
SB/CA
.
FD/CC
.
Loan
Do you have any physical Deformity?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Specify
Do you have any Personal Life insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Personal Life insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Pension Plan policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Pension Plan is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Personal Health Insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Health Insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Govt Plan
Are you aware of any government insurance schemes?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If yes, how did you become aware of the same
--- Select ---
Ward Officials
Advertisements
Family
Friends
Others
Do you have any of the following insurance schemes of the government?
.
PMSBY
.
PMJJBY
.
KASP
.
Ayushman Bharat/ RSBY
.
Others
Are you having an account with any of the following banks
.
SBI
.
SIB
.
CNRB
.
FB
.
KGB
.
KB
.
ICICI
.
HDFC
.
UBI
.
BOB
.
IOB
.
PNB
.
Other
Is your Aadhar card linked with your bank account?
--- Select ---
No
Yes
Dont know
PARENT - MOTHER
Is the Mother of the Head of the Family alive and staying in this house ?
.
Yes
.
No
Mothers Name
Date of Birth
Age
Education
--- Select ---
No Schooling
1 - 4th Std
5th - 9th Std
SSLC/HSE
UG / +2
Graduate
Diploma
Post Graduate
Dont know
Refused to answer
Employment Details. Are you currently
--- Select ---
Employed
Self Employed
Unemployed
Housewife
Retired
Student
Refuse to answer
If Employed, what is your main occupation
--- Select ---
Daily Wage Labourer
Govt Employee
Private Sector
Cooperative Sector
Driver
Legislative/Law enforcement workers
Armed forces
Others
If Self Employed, select
--- Select ---
Trader/ Agent
Agriculturist
Own Taxi
Businessman-0 employees
Businessman-1-9 employees
Businessman-10+ employees
Others
Bank Membership Details
--- Select ---
A - Class
C - Class
D - Class
No Membership
Dont Know
Member Class - Prefer not to say
PSC Bank Account Type
.
SB/CA
.
FD/CC
.
Loan
Do you have any physical Deformity?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Specify
Do you have any Personal Life insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Personal Life insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Pension Plan policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Pension Plan is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Personal Health Insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Health Insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Govt Plan
Are you aware of any government insurance schemes?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If yes, how did you become aware of the same
--- Select ---
Ward Officials
Advertisements
Family
Friends
Others
Do you have any of the following insurance schemes of the government?
.
PMSBY
.
PMJJBY
.
KASP
.
Ayushman Bharat/ RSBY
.
Others
Are you having an account with any of the following banks
.
SBI
.
SIB
.
CNRB
.
FB
.
KGB
.
KB
.
ICICI
.
HDFC
.
UBI
.
BOB
.
IOB
.
PNB
.
Other
Is your Aadhar card linked with your bank account?
--- Select ---
No
Yes
Dont know
PARENT - FATHER IN LAW
Is the Father in Law of the Head of the Family alive and staying in this house ?
.
Yes
.
No
Father in Law Name
Date of Birth
Age
Education
--- Select ---
No Schooling
1 - 4th Std
5th - 9th Std
SSLC/HSE
UG / +2
Graduate
Diploma
Post Graduate
Dont know
Refused to answer
Employment Details. Are you currently
--- Select ---
Employed
Self Employed
Unemployed
Housewife
Retired
Student
Refuse to answer
If Employed, what is your main occupation
--- Select ---
Daily Wage Labourer
Govt Employee
Private Sector
Cooperative Sector
Driver
Legislative/Law enforcement workers
Armed forces
Others
If Self Employed, select
--- Select ---
Trader/ Agent
Agriculturist
Own Taxi
Businessman-0 employees
Businessman-1-9 employees
Businessman-10+ employees
Others
Bank Membership Details
--- Select ---
A - Class
C - Class
D - Class
No Membership
Dont Know
Member Class - Prefer not to say
PSC Bank Account Type
.
SB/CA
.
FD/CC
.
Loan
Do you have any physical Deformity?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Specify
Do you have any Personal Life insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Personal Life insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Pension Plan policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Pension Plan is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Personal Health Insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Health Insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Govt Plan
Are you aware of any government insurance schemes?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If yes, how did you become aware of the same
--- Select ---
Ward Officials
Advertisements
Family
Friends
Others
Do you have any of the following insurance schemes of the government?
.
PMSBY
.
PMJJBY
.
KASP
.
Ayushman Bharat/ RSBY
.
Others
Are you having an account with any of the following banks
.
SBI
.
SIB
.
CNRB
.
FB
.
KGB
.
KB
.
ICICI
.
HDFC
.
UBI
.
BOB
.
IOB
.
PNB
.
Other
Is your Aadhar card linked with your bank account?
--- Select ---
No
Yes
Dont know
PARENT - MOTHER IN LAW
Is the Mother in Law of the Head of the Family alive and staying in this house ?
.
Yes
.
No
Mother in Law Name
Date of Birth
Age
Education
--- Select ---
No Schooling
1 - 4th Std
5th - 9th Std
SSLC/HSE
UG / +2
Graduate
Diploma
Post Graduate
Dont know
Refused to answer
Employment Details. Are you currently
--- Select ---
Employed
Self Employed
Unemployed
Housewife
Retired
Student
Refuse to answer
If Employed, what is your main occupation
--- Select ---
Daily Wage Labourer
Govt Employee
Private Sector
Cooperative Sector
Driver
Legislative/Law enforcement workers
Armed forces
Others
If Self Employed, select
--- Select ---
Trader/ Agent
Agriculturist
Own Taxi
Businessman-0 employees
Businessman-1-9 employees
Businessman-10+ employees
Others
Bank Membership Details
--- Select ---
A - Class
C - Class
D - Class
No Membership
Dont Know
Member Class - Prefer not to say
PSC Bank Account Type
.
SB/CA
.
FD/CC
.
Loan
Do you have any physical Deformity?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Specify
Do you have any Personal Life insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Personal Life insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Pension Plan policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Pension Plan is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Personal Health Insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Health Insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Govt Plan
Are you aware of any government insurance schemes?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If yes, how did you become aware of the same
--- Select ---
Ward Officials
Advertisements
Family
Friends
Others
Do you have any of the following insurance schemes of the government?
.
PMSBY
.
PMJJBY
.
KASP
.
Ayushman Bharat/ RSBY
.
Others
Are you having an account with any of the following banks
.
SBI
.
SIB
.
CNRB
.
FB
.
KGB
.
KB
.
ICICI
.
HDFC
.
UBI
.
BOB
.
IOB
.
PNB
.
Other
Is your Aadhar card linked with your bank account?
--- Select ---
No
Yes
Dont know
Back
Next
Please fill in the details of Unmarried Children residing in the same house.
Do you have any Unmarried Children ?
.
Yes
.
No
1st CHILD DETAILS
1st Child Name
Gender
--- Select ---
Male
Female
3rd Gender
Date of Birth
Age
Education
--- Select ---
No Schooling
1 - 4th Std
5th - 9th Std
SSLC/HSE
UG / +2
Graduate
Diploma
Post Graduate
Dont know
Refused to answer
Employment Details. Are you currently
--- Select ---
Employed
Self Employed
Unemployed
Housewife
Retired
Student
Refuse to answer
If Employed, what is your main occupation
--- Select ---
Daily Wage Labourer
Govt Employee
Private Sector
Cooperative Sector
Driver
Legislative/Law enforcement workers
Armed forces
Others
If Self Employed, select
--- Select ---
Trader/ Agent
Agriculturist
Own Taxi
Businessman-0 employees
Businessman-1-9 employees
Businessman-10+ employees
Others
Bank Membership Details
--- Select ---
A - Class
C - Class
D - Class
No Membership
Dont Know
Member Class - Prefer not to say
PSC Bank Account Type
.
SB/CA
.
FD/CC
.
Loan
Do you have any physical Deformity?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Specify
Do you have any Personal Life insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Personal Life insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Pension Plan policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Pension Plan is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Personal Health Insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Health Insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Govt Plan
Are you aware of any government insurance schemes?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If yes, how did you become aware of the same
--- Select ---
Ward Officials
Advertisements
Family
Friends
Others
Do you have any of the following insurance schemes of the government?
.
PMSBY
.
PMJJBY
.
KASP
.
Ayushman Bharat/ RSBY
.
Others
Are you having an account with any of the following banks
.
SBI
.
SIB
.
CNRB
.
FB
.
KGB
.
KB
.
ICICI
.
HDFC
.
UBI
.
BOB
.
IOB
.
PNB
.
Other
Is your Aadhar card linked with your bank account?
--- Select ---
No
Yes
Dont know
2nd CHILD DETAILS
Do you have an unmarried Second child and staying in this house ?
.
Yes
.
No
2nd Child Name
Gender
--- Select ---
Male
Female
3rd Gender
Date of Birth
Age
Education
--- Select ---
No Schooling
1 - 4th Std
5th - 9th Std
SSLC/HSE
UG / +2
Graduate
Diploma
Post Graduate
Dont know
Refused to answer
Employment Details. Are you currently
--- Select ---
Employed
Self Employed
Unemployed
Housewife
Retired
Student
Refuse to answer
If Employed, what is your main occupation
--- Select ---
Daily Wage Labourer
Govt Employee
Private Sector
Cooperative Sector
Driver
Legislative/Law enforcement workers
Armed forces
Others
If Self Employed, select
--- Select ---
Trader/ Agent
Agriculturist
Own Taxi
Businessman-0 employees
Businessman-1-9 employees
Businessman-10+ employees
Others
Bank Membership Details
--- Select ---
A - Class
C - Class
D - Class
No Membership
Dont Know
Member Class - Prefer not to say
PSC Bank Account Type
.
SB/CA
.
FD/CC
.
Loan
Do you have any physical Deformity?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Specify
Do you have any Personal Life insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Personal Life insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Pension Plan policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Pension Plan is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Personal Health Insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Health Insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Govt Plan
Are you aware of any government insurance schemes?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If yes, how did you become aware of the same
--- Select ---
Ward Officials
Advertisements
Family
Friends
Others
Do you have any of the following insurance schemes of the government?
.
PMSBY
.
PMJJBY
.
KASP
.
Ayushman Bharat/ RSBY
.
Others
Are you having an account with any of the following banks
.
SBI
.
SIB
.
CNRB
.
FB
.
KGB
.
KB
.
ICICI
.
HDFC
.
UBI
.
BOB
.
IOB
.
PNB
.
Other
Is your Aadhar card linked with your bank account?
--- Select ---
No
Yes
Dont know
3rd CHILD DETAILS
Do you have an unmarried Third child and staying in this house ?
.
Yes
.
No
3rd Child Name
Gender
--- Select ---
Male
Female
3rd Gender
Date of Birth
Age
Education
--- Select ---
No Schooling
1 - 4th Std
5th - 9th Std
SSLC/HSE
UG / +2
Graduate
Diploma
Post Graduate
Dont know
Refused to answer
Employment Details. Are you currently
--- Select ---
Employed
Self Employed
Unemployed
Housewife
Retired
Student
Refuse to answer
If Employed, what is your main occupation
--- Select ---
Daily Wage Labourer
Govt Employee
Private Sector
Cooperative Sector
Driver
Legislative/Law enforcement workers
Armed forces
Others
If Self Employed, select
--- Select ---
Trader/ Agent
Agriculturist
Own Taxi
Businessman-0 employees
Businessman-1-9 employees
Businessman-10+ employees
Others
Bank Membership Details
--- Select ---
A - Class
C - Class
D - Class
No Membership
Dont Know
Member Class - Prefer not to say
PSC Bank Account Type
.
SB/CA
.
FD/CC
.
Loan
Do you have any physical Deformity?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Specify
Do you have any Personal Life insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Personal Life insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Pension Plan policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Pension Plan is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Personal Health Insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Health Insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Govt Plan
Are you aware of any government insurance schemes?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If yes, how did you become aware of the same
--- Select ---
Ward Officials
Advertisements
Family
Friends
Others
Do you have any of the following insurance schemes of the government?
.
PMSBY
.
PMJJBY
.
KASP
.
Ayushman Bharat/ RSBY
.
Others
Are you having an account with any of the following banks
.
SBI
.
SIB
.
CNRB
.
FB
.
KGB
.
KB
.
ICICI
.
HDFC
.
UBI
.
BOB
.
IOB
.
PNB
.
Other
Is your Aadhar card linked with your bank account?
--- Select ---
No
Yes
Dont know
4th CHILD DETAILS
Do you have an unmarried Fourth child and staying in this house ?
.
Yes
.
No
4th Child Name
Gender
--- Select ---
Male
Female
3rd Gender
Date of Birth
Age
Education
--- Select ---
No Schooling
1 - 4th Std
5th - 9th Std
SSLC/HSE
UG / +2
Graduate
Diploma
Post Graduate
Dont know
Refused to answer
Employment Details. Are you currently
--- Select ---
Employed
Self Employed
Unemployed
Housewife
Retired
Student
Refuse to answer
If Employed, what is your main occupation
--- Select ---
Daily Wage Labourer
Govt Employee
Private Sector
Cooperative Sector
Driver
Legislative/Law enforcement workers
Armed forces
Others
If Self Employed, select
--- Select ---
Trader/ Agent
Agriculturist
Own Taxi
Businessman-0 employees
Businessman-1-9 employees
Businessman-10+ employees
Others
Bank Membership Details
--- Select ---
A - Class
C - Class
D - Class
No Membership
Dont Know
Member Class - Prefer not to say
PSC Bank Account Type
.
SB/CA
.
FD/CC
.
Loan
Do you have any physical Deformity?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Specify
Do you have any Personal Life insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Personal Life insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Pension Plan policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Pension Plan is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Personal Health Insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Health Insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Govt Plan
Are you aware of any government insurance schemes?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If yes, how did you become aware of the same
--- Select ---
Ward Officials
Advertisements
Family
Friends
Others
Do you have any of the following insurance schemes of the government?
.
PMSBY
.
PMJJBY
.
KASP
.
Ayushman Bharat/ RSBY
.
Others
Are you having an account with any of the following banks
.
SBI
.
SIB
.
CNRB
.
FB
.
KGB
.
KB
.
ICICI
.
HDFC
.
UBI
.
BOB
.
IOB
.
PNB
.
Other
Is your Aadhar card linked with your bank account?
--- Select ---
No
Yes
Dont know
5th CHILD DETAILS
Do you have an unmarried Fifth child and staying in this house ?
.
Yes
.
No
5th Child Name
Gender
--- Select ---
Male
Female
3rd Gender
Date of Birth
Age
Education
--- Select ---
No Schooling
1 - 4th Std
5th - 9th Std
SSLC/HSE
UG / +2
Graduate
Diploma
Post Graduate
Dont know
Refused to answer
Employment Details. Are you currently
--- Select ---
Employed
Self Employed
Unemployed
Housewife
Retired
Student
Refuse to answer
If Employed, what is your main occupation
--- Select ---
Daily Wage Labourer
Govt Employee
Private Sector
Cooperative Sector
Driver
Legislative/Law enforcement workers
Armed forces
Others
If Self Employed, select
--- Select ---
Trader/ Agent
Agriculturist
Own Taxi
Businessman-0 employees
Businessman-1-9 employees
Businessman-10+ employees
Others
Bank Membership Details
--- Select ---
A - Class
C - Class
D - Class
No Membership
Dont Know
Member Class - Prefer not to say
PSC Bank Account Type
.
SB/CA
.
FD/CC
.
Loan
Do you have any physical Deformity?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Specify
Do you have any Personal Life insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Personal Life insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Pension Plan policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Pension Plan is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Do you have any Personal Health Insurance policy?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If Yes, Health Insurance is with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Govt Plan
Are you aware of any government insurance schemes?
--- Select ---
No
Yes
Dont know
Refuse to Answer
If yes, how did you become aware of the same
--- Select ---
Ward Officials
Advertisements
Family
Friends
Others
Do you have any of the following insurance schemes of the government?
.
PMSBY
.
PMJJBY
.
KASP
.
Ayushman Bharat/ RSBY
.
Others
Are you having an account with any of the following banks
.
SBI
.
SIB
.
CNRB
.
FB
.
KGB
.
KB
.
ICICI
.
HDFC
.
UBI
.
BOB
.
IOB
.
PNB
.
Other
Is your Aadhar card linked with your bank account?
--- Select ---
No
Yes
Dont know
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Bank Questionnaire
Who do you approach for your medical needs?
--- Select ---
Government
Private
Both
Your Choice for education
--- Select ---
Government
Private
Both
What is the main source of water supply for your household?
--- Select ---
Well
Pond
Panchayat Water supply
Other
Are you suffering from any of the Lifestyle Diseases?
--- Select ---
Heart disease
Stroke
Diabetes
Obesity
Metabolic syndrome
Chronic obstructive pulmonary disease
Any type of cancer
Other
Was there any death in the family in the last five years?
--- Select ---
No
Yes
If Yes, Cause of death?
--- Select ---
Disease
Accident
Suicide
Other
Year of Death
Total ownership of land?
--- Select ---
Nil
Upto 10 cents
10-50 cents
50 cents - 1 acre
1 acre above
Refuse to answer
Details of the ownership of livestock
.
Cow/Buffalo
.
Goat
.
Hen
.
Other Pets
Major agricultural crops cultivated
.
Coconut
.
Rubber
.
Arecanut
.
Cocoa
.
Pepper
.
Nutmeg
.
Rice/Paddy
.
Banana
.
Turmeric
.
Others
Are the Crops insured ?
--- Select ---
No
Yes
If yes, insured with
--- Select ---
PMFBY
State Insurance
Public Sector Insurer
Private Sector Insurer
Others
Do you own a vehicle?
.
Yes
.
No
Choose type of vehicle owned.
.
Bike/Scooter
.
Auto
.
Car/Jeep
.
Van/Mini Lorry
.
Truck/Lorry
.
Tractor
.
Others
Do you have insurance for these vehicle /vehicles?
--- Select ---
No
Yes
If yes, vehcile insured with
--- Select ---
Public Sector Insurer
Private Sector Insurer
Are you interested in small scale entrepreneurship ?
--- Select ---
No
Yes
If Yes, Which area/type
--- Select ---
Agriculture
Life Stock/ Animal Husbandry
Manufacturing
Digital
Retail Shop/Service Centre
Others
Non Decided
Other Details (if any)
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Next
Remarks
*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.
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