| Name of Insured | _NameOfInsured |
| Policy Period | _PolicyPeriod |
| Head Office Address | _HeadOfficeAddress |
| Risk Address | _RiskAddress |
| Nature of Work | _NatureOfWork |
| Cover | _Cover |
| Type of Employees Covered | _TypeOfEmployeesCovered |
| Excluded Employees | _ExcludedEmployees |
| Employees | _Employees |
| Estimated Annual Salary or Wages (Rs.) | _EstimatedAnnualSalaryOrWages |
| Cover Under WC/EC | _UnderWCEC |
| Cover Under Fatal Accident | _UnderFatalAccident |
| Cover Under Common Law | _UnderCommonLaw |
| Buffer % | _BufferPercentage |
| Medical Extension | _MedicalExtension |
| Medical Extension Limit | _MELimit |
| Occupation Disease | _OccupationDisease |
| Conditions | |
| Territory | _Territory |
| Jurisdiction | _Jurisdiction |
| Claim History | _ClaimHistory |
