Download as pdf or txt
Download as pdf or txt
You are on page 1of 1

Beneficiary Nomination Form

PLAN NAME:
POLICY NUMBER:
EMPLOYEE NUMBER:

BENEFICIARY DETAILS

Name of Proof of Identity ** Relationship to the Life % Share of benefit


Beneficiary * Assured

* If minor, the details of the guardian with proof of identity required


** Original certified copy required.

EMPLOYEE SIGNATURE:

(1) NAME …………. SIGNATURE …………. DATE ………….

For (Policyholder) HR use only


Date of receipt of Form:
Received By:
Signature:

You might also like