Jubilee Insurance

Employee Name: ____________________________ CNIC No.: ______________________________

Department: _____________________________ Date of Birth: _________________________

Marital Status: Single Married

I have opted for medical insurance option of:
Rs. 100,000 (no deduction from salary)
Rs. 300,000 (200 for employees and 330 per dependent)
Rs. 500,000 (400 for employees and 550 per dependent)
*Fixed premium of Rs. 660 for each Parent enrolled will be deducted under 300,000 or 500,000 policy plan.

Dependents age should be:

- Spouse 65 years or less
(Maternity included for married females under 45 years)
- Child 25 years or less (unmarried)
- Sibling 25 years or less (unmarried)
- Parents 75 years or less

Family members details are as follow: (Family members have same options as mentioned above)

Relation Marital
with DoB - Status -
Family Family Family
Name of Family Member Member Member CNIC-Family Member Member

Signature: _______________________ Date: ___________________

Medical Insurance HO HR -02