Devashrayam - Niramaya Online Registration Enrolment Form

What is Niramaya?

CLAIM FORM

(Health Insurance Scheme for Persons with Disabilities under the National Trust Act)

ENROLMENT FORM
Name of Person with Disability(PwD)
UDID
Aadhar No. of PwD
Father's/Husband's Name
Date of Birth
Sex	Male Female
Status	Married Unmarried
Type of Disability	Tick here	Percentage(%)
a) Autism (A/U)
b) Cerebral Plasy (C/P)
c) Mental Retradation (M/R)
d) Multiple Disability (M/D)
Please specify atleast two Disabilities if M/D
Family Status	BPL APL
Name of Nominee
Relationship with PwD
House Name
Place
Post Office
Pincode
Mobile Number
District
Whatsapp Number
Mail ID
Bank Account Details
Account Holder Name
Account Number
Bank Name
Branch Name
IFSC No.
City
Attachments (Copy)
UDID Certificate (.pdf Format only)
Aadhaar of PwD (.pdf Format only)
Disability Certificate (.pdf Format only)
Ration Card (.pdf Format only)
Bank Passbook (.pdf Format only)
Passport Size Photo (.jpeg Format only)