Nomination & Declaration Form

For Group Health, Life And Personal Accident Insurance Plans

1. Name (In Block Letters) DODLA KANTHARAO

: _____________________________________________________

2. Employee Code 140991

: ________________________________________________________

3. Dodla Pedda Basaiah

: ________________________________________________________

4. Date of Birth 10/06/1994

: ________________________________________________________

5. Sex Male
: ________________________________________________________

6. Marital Status Single

: ________________________________________________________

7. Address Permanent 1/103,Near to post office,Paigeri Street,Ganjihalli,

: ________________________________________________________

Gonegandla,Kurnool,A.P, PIN:518463
________________________________________________________

Temporary Sri Sai Krishna Luxury PG,No1194,8th Cross ,Near

: ________________________________________________________

Ramamurthinagar,TC Palya Main Road,Bangalore-560016

________________________________________________________

Date of Joining 05/11/2020

: ________________________________________________________
 PART A Term Life Insurance Plan
I hereby cancel the nomination(s) made by me previously and nominate the person(s) mentioned
below to receive the amount standing to my credit in the Term Life Insurance Policy, in the event of my
death. Please ensure percentage of share totals to 100%.
Name & Address of Date of Total percentage of If the nominee is minor,
the Nominee/ relationship with the Birth share of Term Life please give name & address
Nominees Employee Insurance benefit to & relationship of the
be paid to each guardian who may receive
nominee the amount

Name:
Dolda Pedda Basaiah
Address: Father 01/02/1960 30%
1/103,Near to post --
office,Paigeri Street,
Ganjihalli,Gonegandla
Kurnool,A.P-518463
Name:Dodla
Rameswaramma
Mother 04/07/1958 70% --
Address:
1/103,Near to post
office,Paigeri Street,
Ganjihalli,Gonegandla
Kurnool,A.P-518463

PART B Personal Accident Insurance Plan

I hereby cancel the nomination(s) made by me previously and nominate the person(s) mentioned
below to receive the amount standing to my credit in the Personal Accident Insurance Policy, in the
event of my death. Please ensure percentage of share totals to 100%.
If you would like to allocate in the same % as Part A Life Insurance, please tick this box,
alternatively complete details below:
Name & Address of Date of Total percentage of If the nominee is minor,
the Nominee/ relationship with the Birth share of Personal please give name & address
Nominees Employee Accident Insurance & relationship of the
benefit to be paid to guardian who may receive
each nominee the amount
Name:
Dolda Pedda Basaiah
Address:
1/103,Near to post
office,Paigeri Street, Father 01/02/1960 30% ---
Ganjihalli,Gonegandla
Kurnool,A.P-518463
Name:Dodla
Rameswaramma 04/07/1958 70% ---
Mother
Address:
1/103,Near to post
office,Paigeri Street,
Ganjihalli,Gonegandla
Kurnool,A.P-518463

Signature of the Employee: ___________________ 6/11/2020

Date:_______________