K. K.

Wagh Education Society, Nashik -03

Information for Staff Group Medi-claim Policy
Name of Institute : - K. K. Wagh Institute of Engineering Education and Research, Nashik
Name of Department : - Production Engineering
Name of Staff : - Mr. Dhage Santosh Popat
Type (Regular / Ad-hoc):- Regular
If Ad-hoc then Order period: - From to
Designation : - Peon
Gross Salary : - Rs. 22255/-
Permanent Address : - Vinitanagar, Holkar nagar, ugaon road, Niphad, Pin code-422303
Email ID : - spdhage@kkwagh.edu.in
Mob. No. : - 9921369233
Medi-claim option 1 lakh / 2 lakh. : - 1 lakh
Details of Family members:-
Sr.No. Name Relation Date of Birth Age
1 Dhage Santosh Popat Self 09/06/1974 43
2 Dhage Ranjana Santosh Wife 07/01/1977 40
3 Dhage Shubham santosh Son / Daughter 30/06/1997 20
4 Dhage Dhanashri Santosh Son / Daughter 09/01/1999 18
5 Father
6 Dhage Lilabai Popat Mother 04/07/1940 77

Note : - 1) Children only below 25 years of age are allowed.

2) As per IRDA guidelines only female employees are allowed to give name of either
In laws or Parents.
I Dhage Santosh Popat do hereby verify that the information stated above is true.

Date: - Name & Signature of staff