Annexure-VII

NEW HEALTH INSURANCE SCHEME, 2021

for Employees of Govt. Departments and Organisations covered under this Scheme
Form for furnishing Data of Employee and their eligible Family
Members for insurance coverage under New Health Insurance Scheme,
2021 to Insurance Company/Third Party Administrator.

1. Name of the Employee : R.SARAVANAN

[In case the spouse is employed, the details of the
spouse shall also be furnished in the same format
separatey].

2. Contact Mobile No. : 9445946568

3. Designation : ASSISTANT

4. NHIS 2012 ID Card No. :

5. Pay Drawn Particulars : Pay in PB + Grade Pay =Total

5200 + 2800 = 8000 (PB1-5200-20200+GP2800)
6. Head of Account in which the Govt.
Employee’s contribution is being
recovered.
: 2202 02 101 AA

7. Type of Office : GOVERNMENT

[Govt. / PSU & SB / Local Bodies /
Universities / Organisations / Institutions]

8. HOD Code : 0 4 3 0 3
[as provided in Budget documents]

9. Office in which Employed : DISTRICT EDUCATIONAL OFFICE,TINDIVANAM,

VILLUPURAM DISTRICT.

10. Date of Birth : 27.06.1989

11. Date of Appointment : 06.02.2017

12. Date of Retirement : 30.06.2049

13. Designation of Drawing & : DEO & SB301
Disbursing Officer & Code

14. Pay Drawing Office attached : SUB–TREASURY ,TINDIVANAM,VILLUPURAM DIST.

[PAO / Treasury / Sub-Treasury with Address for Govt.
Employees]
(Others – Address of the Office)

15. Employee Code : 7000317804 / EDN

[GPF/TPF/CPS No. for Govt. Employees]
[In case of new applicants, state whether application for enrolment in the Contributory Pension Scheme has been sent to the Govt. Data Centre with details of reference no. and
date. Employee code of other organisations, if any assigned shall be indicated along with the identification of the Organisation]
 16. Aadhar No. : 4849 0559 4041
Voter ID No. : DSK2817807
PAN : DXJPS7748E
17. Details of the Employee and their :
eligible Family Members under the
NHIS, 2016

Whether
Date of Relationship Physically
Sl. Name Birth to the Marital Employment Challenged/ Passport size
No. Employee Status Status Mentally Photo
Retarded.**
(Yes/No)

R.SARAVANAN 27.06.1989 MARRIED GOVT NO

1. Self EMPLOYEE

2. S.NATHIYA 03.05.1989 WIFE MARRIED HOUSE NO

WIFE

3. S.INIYAN 27.04.2017 SON UN MARRIED UN EMPLOYEE NO

S.KIRUTHIKA 21.08.2021 DUTORE UN MARRIED UN EMPLOYEE NO

4

** Details of Physically Challenged and Mentally Retarded Children as ordered in para 4 of Annexure-I of the GO to be furnished.

Signature of the Employee

Certified that the above particulars are verified with the Service Register of the
Employee.
Signature of Drawing and Disbursing Officer in
Government Departments

Signature of Pay Drawing Officers in

Organisations covered under this Scheme.

Name :
Designation :
Date :
Seal :