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4

IiIAX BTJPA HEALTH INSURANCE COII/IPANY LTO.

FORM FOR AOMISSION UNDER COI/PANY MEDICLAIi/I POLICY

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a,.nrs n h1r rrave no business or em

oi ki.ur ql,le.f hes Ih o'

Plinl mre: knorn cond tions

Name Add.ess & Teephone nomber of ramly doclor (This informatioi is essenl a)
 MAX BIJPA HEALTH INSI'RANCE COMPANY

EMPLOYEE'NFORMATION SHEET
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FORI' OF APPOINTIIIENT OF NOIIIINATION

Max Bupa Health nsuEne companv Lmred Emplov€es Group Grztu'tv

Fxnd Ded Sns

, a * + *t:t.*|.o#R .f"f ,ffb# (*!r,,nsu6n@ 'p

company Lim,,€d Emproyees'
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'B;' b€rore lhe amount be@@ pav?be and havins becomins pavab e has

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Nam. in iirw(h lull address ol

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:) I hereby cenrry lhal lhe persoi(s) me.riooed hereinabove iJare mv wle /crrldren/lai4ulv
adopred ch d/dependanl parenls/husband
of
|) he.eby declare that L have no famv and shouid acquire lamiv herearle' the 'ppoinlm€nl
No'nnee should be dee ed as cancelled

1) [4y ratherholhe/pareds/sste(s),m nor b.olhe. {s) is/,re nol dependenl on me

5) l\,ly husband's falherpa@nts idarc noldependeiton re.

/) rr.o oeda€ lnal lhE aDoo rrn- . o. No1 .e€r'. .ddp re 4n sh"
rerc.mo F dDponmn' d No n "' Tha" no \o '

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is'onaLUre or Member (EmProts4

Two Wlies*s to the signature

 Pe3se sl ke tlr3r wh ch s nor apptcabre 1o you
:. where an Empoye/lvembe lrre tme or appoinhg. Nom@. rrre N.minallon
n ravour or the Nrembe6 fam y only. Any Nomialon frade by such Employee in
f.vour of any olher persons nol belono'no to his lamily shalbe nvalid
I An apponlmenl oI Nominee made by rhe Membe. can be chansed al ary lme afle. g vlng a wilten
notice lo tlre Trusre ol h s inlenlion ro do so. rhe Nominee pred*ases lhe Member (Enployee) or
't
l The appo ntlMt of Nomln@ or chang€ rhereol made from lime to lime shall iake etfecl to (he enent
I s valid on lhe date on Mich il is recelved by lhe Trusl@s

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Y

TO WHOMSOEVER IT MAY CONCERN

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employee of Max Bupa Health lnsurance Co. Lld
having employee lD , do hereby declare, confirm and
state that as on date ofthis declaration, none ofmy relative
including spouse, deperdent children ordependent step
children, whether residing rlrlh me orDol are working as an
agent or employee with ihe company. li is furlher declared and
afiirmed that as and when any ofthe relatives applies for and/or
becomes an agentoran employee ofthecompanyor
approaches the company for acting as an agent or for seeklng
employment, I shallduly inform the company (repofiing
r.anager and Human Resource team) in writing regarding the

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Deslgnation of the employee J<. +i o -

Dat€ l9-t^-2?>)
Employee Number

Branch/Location: 4 ll t O, f Srr'
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TOWHOMSOEVER IT MAY CONCERN

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lnsurance Co. Ltd., having employee lD-, do hereby

declare and state that as on date ofthis declaration fo lowing of
my relatives are working as empl6yee/individualagent ofthe
company as perthe details given below:

Sr No Relationship Current Employed

wilh Relative Desrgnation S nce

the relative in
I\rax Bupa

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K. .HO$q c?ta,qP' PTOOL)/,4 - t<z?l,a.8 gj,on la- B,*q

Ndmb otlhe Er',ployee s€natu"e'

Designation ofthe employee-- J<'aDo Date lb-19'ao'3

Employee lD:

Branch/Localion' 4 ti+ ,a"fst,ra \

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(For

NOMINATION ANO DECLARATION fOBT.rl

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lD{ aurioi and Nominal on Fdm unrrs lhe EophFes
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Name.nd address oI the Nominee

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Dded,he / ?- D:2e)J

CEFNACATE BY EII!PLOYER

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