IGI LIFE EMPLOYEE / DEPENDENT ADDITION FORM

Dear Insured / Member

Please fill in the required information in order to get yourself / family enrolled in the system

Employee Detail Dependent 1

IBM
Emp. Marital IBM Date of CNIC
Employee Gender DOJ DOB Employee Name 1 Gender
Name Status Location Birth Relationship No.
No. CNIC No.

Dependent 2

Date of CNIC
Name 2 Gender
Birth Relationship No.

Dependent 3

Date of CNIC
Name 3 Gender
Birth Relationship No.

Dependent 4

Date of CNIC
Name 4 Gender
Birth Relationship No.

.
 Note:

Only 4 dependents can be added to the plan (You can enroll 1 spouse + 3 children or 4 children & no spouse)
Cover does not include Parents.

Disclaimer

I hereby agree that this information is completely confidential in nature and intended solely for the processing health insurance of
myself and dependents. I expect that IGI will assume all the liability of data protection in this regard as per local laws of Pakistan.

Employee Name:
IBM Employee number:
Signature