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The Manrgirg Direcror & CEO

Max Bura Llealth InsunnceCoDp.iy Lnnited
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 MAX SUPA HEALTH INSURANCE COMPANY LTD.

FORM FOR ADI\4ISSION UNDER COMPANY I\,IED CLA I',I POL CY

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Deoendair Parenls/ Parenrs our 3 rick rtrue&cross f

Ihe named parenls are mypared

M Darent, parents n a!! are supponed bymeaone

hnNn Med(a Problem5 ( P an lnown.ondrons)

'nd.are

Nade Address & Telephone number oflamily doctor (Trris nformalonisessenlia)

 MAX BUPA HEALTH INSURAN CE COMPAN

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Name ( i Bocr e e6: sumame Ftsr)

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 En p roy m.nl Recod lc hEnologicai o d.4
atach separare shee(, trcquied

hr!e Lo be menroned mandahr rl

Fu dorairsor&nisrbddraM(iruiempbyed) Emorume^ts:

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 FORM OF APPOINTIIIENT OF NOII/|IiIATION

M.xBupa Health nsu6bce Compaiy LLmiled Employ€es Group Gratu ly

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B p" .""rh l.t'anr Co.pcn, I'nied .npor..\
Group craturty Fund hereby aqee to abid€ by the Rules of the said Fuod and do also hereby appoint
nomineds in terms of Rure 13 olrhe Rules mentoned hereu^derlo re@ve tre benelils payable under
lhe Fund n lhe event of my death before lhe amount be@m* payabe aid having becom ng payable has

r) I hereby drecl lhat lhe benenls under lhe Fund p4€ble in rsped ol me sha be pad to lhe
said Nominee/s in prcponion rnd cated aga ns( lheir respslve names as gven below:

Name in lurr w lh fu I address of

Nomineds Ben€fc aryl es

{AN r4 P{ m l4+{,+Al CpoL(,L

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lr I hereby cediy thal Ihe pe6on(s) mentoned here'nabdve dare hy wre /.h dren/a{'luly
adopted ch Ld/dependanr parenls/husband

1) hereby dedrare thar rra€ no ramiy and sho(rd acqurefamily hereatrer rhe app!nhenr.l

My rahe n mol herpa rentgsisle(s)rminor brol her (s) s/a r€ nor de @ndenl on me

My husband s falhe/parenls ivare nol dependenl on me.

6) ae d ecrare Ihal lhrs appoinhe nr of Nom ne/s made heEin shal have the ellecl of my
rcvoking the appointmenl of Nom nee/s made by me earlier Thanklng you,

Anat"t.,t" {Yt'ern'?
{S snarure or Mamber rEmpoyee)

lwo tryiheses 1o lhe s:gnarure :

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r Pease str ke lhal wrr ch s norappll.abelo you
I rAnerc an Empioyeell,lenber has a am ]r 0re tfre or app.ritrg a Nomn€e. the Noninalbn
/
sholld be made in tavour or the [rembe.s fam ly ony Any Nominalion tade by su.h Employee n
favour ol anv othd persons not belonoina lo his familY slrall be nva id
i An apponlment oJ Ndm dee made by lhe Member can be changed !t any ume after gvng a winen
noli@ lo lhe Truslees ofhis intenton to do so lthe Nomne prcd&eases lhe i\,lember (Empoye)0r

l The appoinhent of Nominee or chanqe lhereof made from time lo l me shax take effecl to lhe enent
it is va d on the dare on which l is reGived by rhe Trusles

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 TO WHOMSOEVER iT MAY CONCERN

L,\n ti ,no }+A,,JD Y

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. employee of lvlax Bupa Heallh lnsurance Co. Ltd..
having employee lD-, do hereby declare, confirm and
state that as on date ofthis declaration, none of my relative
including spouse, depe,dent children ordependent step
chilclrcn, whethet residing MIh me ornol are working as an
agent or employee with the company. li is iurther declared and
affirmed that as and when any of lhe relatives applies for and/or
becomes an agentor an employee of the companyor
approaches the com pany ior acting as an agent orfor seeking
employment, I shall duly inform the company (reporting
manager and Human Resource team) n writing regarding the

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he Employee: Signalure:
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Desiqnation of the employ
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Branch/Location: DU
 TO WHOMSOEVER IT MAYCONCERN

fn+Dll uynr 'i4- /ND d+NT ax Bupa Health

lnsurance Co Ltd. havrng employee lD do hereby
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declare and state ihat as on date ofthis declaration lollowing
my relatives are working as employee/individual agent ofthe
company as per the details given below: -,

RelationshiP Current Employed

Sr. No.
Designation Since
Name

Max Bupa

nn l+u\nt f n-av rttv'tr'I hfe6,

Name of the Employee Signalure:

Desrgnation ol the employ.. NDO oate / ,4 I , \

Employee lD

Branch/Locatron: 9ry)L
 CONII'ANY NAIIlj
COTIPOSI'I'E INFORIIATION STIEET

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PROVIDENT FUND DE'TAII,S

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 FORM 2 lRevke.l)

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NOIIiINATION AND DECTAFATION FORM

lD( aEriDn rd Nominaloi Fdm mdd lie En p orees Prorde n r F mds and Empl.yees Psm $ Scheme)

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rhereby nomrnare ftepe6onG)hlic syand nominara, rho peao(s) nenrioied

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Name and addrcss orihe lamlly members

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rined in para 2(vri) or Employeas' Pei

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