Scribd Logo
Upload

Welcome to Scribd!

  • 18.medical Insurance Enrollment Form

    Uploaded by

    Kratika Pandey
    81 views2 pages
    This document is an enrollment form for medical insurance. It requests information such as the employee's name, date of birth, designation, marital status, and department. It also asks for details of up to five family dependents that can be covered under the insurance policy. These include spouse, children, parents, and in-laws. The form notes that it can also be used by existing employees to update their dependent details. It provides important details about the insurance provider, third party administrator, support helpline contact information, escalation process, and a link to the list of network hospitals.

    Original Description:

    kp

    Original Title

    18.Medical Insurance Enrollment Form

    Copyright

    © © All Rights Reserved

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document is an enrollment form for medical insurance. It requests information such as the employee's name, date of birth, designation, marital status, and department. It also asks for details of up to five family dependents that can be covered under the insurance policy. These include spouse, children, parents, and in-laws. The form notes that it can also be used by existing employees to update their dependent details. It provides important details about the insurance provider, third party administrator, support helpline contact information, escalation process, and a link to the list of network hospitals.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    81 views2 pages

    18.medical Insurance Enrollment Form

    Uploaded by

    Kratika Pandey
    This document is an enrollment form for medical insurance. It requests information such as the employee's name, date of birth, designation, marital status, and department. It also asks for details of up to five family dependents that can be covered under the insurance policy. These include spouse, children, parents, and in-laws. The form notes that it can also be used by existing employees to update their dependent details. It provides important details about the insurance provider, third party administrator, support helpline contact information, escalation process, and a link to the list of network hospitals.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    of 2

    Enrollment form for Medical

    Insurance
    (Please enter in BLOCK LETTERS)
    Employees
    Mr./Mrs./ Ms:
    Name :
    FIRST NAME

    MIDDLENAME

    SURNAME
    Employee
    No:
    Designation
    :
    Marital
    Status:
    Date of
    Joining:

    Date of birth:
    Grade:
    Date of
    Marriage:
    Department/
    Team:

    Mobile No:

    Email Id:

    Details of family dependents for enrollment:


    Family Dependents Definition: Family Floater policy (Self + 3)
    Married : Self + Spouse + 2 children
    Unmarried: Self + Two Dependent Parents
    Divorced (with child) : Self + Two children
    Divorced (without child) : Self + Two Dependent Parents/ in laws
    Sr.
    No

    Name

    Gend
    er

    Date Of
    Birth

    Ag
    e

    Relationshi
    p

    Occupatio
    n

    1
    2
    3
    4
    5
    I certify that the particulars mentioned above are true to the best of my knowledge
    and belief.
    Date

    : ________________

    Signature: _____________________

    Tear off You may cut along this line and keep details displayed below for your
    reference

    Important Medical Insurance Details


    Insurance Provider The New India Assurance Company Limited
    Third Party Administrator (TPA) Family Health Plan Limited (FHPL)
    Support Helpline Dedicated 08652033111 (Working Hrs) or 1800 425 4033 (24X7)
    email: gsk@fhpl.net
    Please note that this form can be used by existing employees to update their dependent
    details.

    Enrollment form for Medical


    Insurance

    Escalation matrix 1st Level Raghu (FHPL) 09223329003, 2nd Level Santosh
    (Almondz) 09004050205
    FAQ and Details on the medical insurance cover as applicable to you are available on
    the intranet (connectGSK). If you do not have access to the intranet, please request
    your line manager for the details
    You will receive the cashless insurance cards about 3 months from date of joining on
    your GSK email id
    List
    of
    network
    hospitals
    is
    available
    online
    at:
    https://www.fhpl.net/NetworkHospitals/NWHospitals.aspx

    Please note that this form can be used by existing employees to update their dependent
    details.

    You might also like