Name _________________________

Date _________________________

Note:
1. Maximum number of family members for medical nomination (including employee) should not exceed six.
2. Please do not include your own name in the nomination section
3. Family members means spouse, children, parents and parents-in-law of employee

Name Gender Date of Birth

Life Insurance nominee
Group Accident Insurance nominee

Provident Fund

Date of Birth Dependent Nominees for Provident

Sr. no. Name Relationship Gender
(DD/MM/YYYY) (yes/no) Fund (yes\no)

Gratuity

Date of Birth Dependent Nominees for Gratuity

Sr. no. Name Relationship Gender
(DD/MM/YYYY) (yes/no) (yes\no)

1
2
3
4
5

Mediclaim

Date of Birth Dependent Nominees for Mediclaim

Sr. no. Name Relationship Gender
(DD/MM/YYYY) (yes/no) coverage (yes\no)

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