Beneficiary Nomination Form

Group Policy Number

Group Policy Holder(Employer)
Name
Member Employee Details – To be completed by the employee.
1. Full Name of Member/ Employee

2. Date of Birth D D M M Y Y Y Y 3. Gender Male Female

4. Marital Status (Use ) Single Married Others_____________________________
5. Unique Member / Employee id/
Group Company Code (If any)

6. Address
(Number, Street, City, State, Pin
Code)

7. Amount of coverage requested: Graded

8. Nominations
In the event of my death, I wish my benefits under the above mentioned Group Policy be apportioned between my nominated
beneficiary (ies) as follows. The following nomination invalidates all such nominations made prior to the date of this nomination.
% of Appointee Details in case
S.No. Nominee Name Date of Birth Relationship
Benefit the Nominee is a Minor

Total Percentage of Benefits 100 %

Date:

Place:
Signature of Member / Employee:
Employer Attestation – to be completed by an authorised personnel of the Policy Holder

Designation :
Date :

Place :
Authorised Signatory:

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