Cotiviti India

Joining Formalites Checklist

Employee Name SHREYA ASHOK JAIN Date of Joining 19/10/23

Emp Code Date Checked

Sl.No Documents Please tick appropriate box

New Joiner
HR Executive Remarks / Action for closure
(Y/N)
TO BE FILLED BY EMPLOYEE Y
(Put Y/N on documents which are applicable)
1 Certificate 10th* Yes
2 Certificate 12th * Yes
3 Certification - Graduation* Yes
4 Certificate - Post Graduation (If applicable) No
5 Passport Size color photograph
6 Passport copy Yes
7 Driving Licencee copy No
8 PAN Card Copy* Yes
9 UAN No Yes
10 Aadhar * Yes
11 Family Photograph (Self + Mother + Father+ Wife / Husband/Children) for ESI No
12 Resignation Acceptance Letter / LWD Confirmation* Yes
13 Relieving Letter Copy* Yes
14 Undertaking Letter in case of non submission of relieving letter No
15 Payslip of last month from previous employer* Yes
16 Previous Expereince letters ( lastest / current employment)* Yes

TO BE FILLED BY HR TEAM
17 Resume *
18 Assessment Sheet - Technical *
19 Assessment Sheet - HR *
20 Acceptance of Offer Letter *
21 Appointment Letter *
22 Non Disclosure Agreement (Agreement with all Exhibits) *
23 Service Agreement (If applicable)
24 Medical Nomination Form
25 Employee Profile Form *
26 PF Nomination Forms *
27 Gratuity Nomination Form *
28 Travel /Relocation claims with Original Tickets if applicable
* Mandatory
Note:
All the certificates mentioned above to be photcopied and submitted to HR,
shall be verified on the date of Joining.

SHREYA A. JAIN

Signature of Employee Signature - HR Team Member

 Cotiviti India Private Limited
EMPLOYEE INFORMATION SHEET
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Please fill in the following details ###
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Salutation ###
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First Name ###
* ###
Middle Name Instructions for Name columns: Please write the First, Middle and Last Names, with out any spaces in ###
between. First Name and Last Name columns are ###
Last Name mandatory, as your email id is going to be based on them.Please expand all initials. ###
###
Sex: ###
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Blood Group ###
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Date of Joining ###
Photograph ###
Designation ###
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Department ###
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Date of Birth (As per certificate) Date of Birth (Original) ###
###
Marital Status ###
###
Have you ever worked in Cotiviti if yes, Specify your Emp No. ###
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Contact Information ###
###
Personal Emai ID ###
###
Mobile No ###
###
Land Line Phone No Father Name ###
###
Present ###
Address ###
Present Ad
Permanent Ad
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Ph No ###
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Permanent ###
Address ###
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Ph No ###
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Home Location ###
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Emergency Contact Information ###
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Contact Person Relation Address Telephone ###

AASHIKA JAIN COUSIN ZEAL COLLEGE , NARHE, PUNE 9404443173 ###

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Nationality Indian If Non-Indian please specify your nationality ###
Please confirm possession of valid work Permit ###
Citizenship If yes, Please specify validity. ###
###
--
Passport Details ###
###
Do you have a valid passport Yes ###
###
Date of Issue: Passport No: Type of Visa ###
###
###
Expiry Date: Place of issue: Expiry Date ###
DD MM YYYY DD MM YYYY ###
###

PAN Card No BHCPJ4056M UAN No 101685082929 ###

###
TAN(temp acknowledgment#) Aadhar No 2626 2414 0234 ###
Name
(If Applicable) as per Aadhar SHREYA ASHOK JAIN ###

Educational Qualifications ###

###
Degree/ Diploma Subject / Branch College & University From To Class Obt % ###
AMRAVATI DIVISION , PUNE ###
X std STATE BOARD 92
2010 2011 ###

XII std AMRAVATI DIVISION BOARD 75 ###

If Others STATE BOARD 2012 2013 ###

Graduation M.U.H.S NASHIK 62

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2013 2019 ###

PG ###
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Is your Post Graduation a professional qualification? (Professional Qualifications:CA, ICWA, MBBS etc) ###
Please let us know on the date of joining, if you have more number of qualifications, than the columns provided. ###
Work History (Starting from your last employer) ###
###
From To Annual ###
Organization & Location Designation Date Month Year Date Month Year Gross Pay ###
Last Org NANDURA ###
Location NANDURA, BULDANA PHYSICIAN 1 Mar 2019 1 Jul 2023 VISITING FROM
Prev 1 SAHYADRI SUPERCIALITY HOSPITALS 1-Mar-2019
Location PUNE CLINICAL ASSISTANT 29 Nov 2021 25 Jan 2023 3 LPA --
Prev 2 MMF JOSHI HOSPITAL 29-Nov-2021
Location PUNE CLINICAL ASSISTANT 6 Apr 2021 31 Oct 2021 2.16 LPA --
Prev 3 6-Apr-2021
Location --
Prev 4 --
Location --
Prev 5 --
Location --
Prev 6 --
Location --
Please let us know on the date of joining, if you have worked with more companies, than the columns provided. --

Total Work Experience 4 YRS Relevant Work Experience to the job offered 4 YRS

Trainings Attended:

Course Title Name of the Institute Duration Month Year

PGD MCAH THE OTHER SONG , MUMBAI 6 MONTHS Jul 2019

PGDEMS RUBY HALL CLINIC PUNE 6 MONTHS Apr

Membership of Professional Bodies:

Institution Type of membership Valid upto

SHREYA A. JAIN

Signature of Employee
Date
 Cotiviti India Private Limited
JOINING REPORT

Name in full : SHREYA ASHOK JAIN

Address : 54/b3 , Damodar Villa , kothrud, p=Pune 411038

To
AVP - Human Resources

I hereby report for duty to-day i.e _____________________________________________________________

In the position of CLINICAL CONTENT ANALYST

FOR OFFICE USE ONLY

Sri/Smt:_________________________________________________________ has been engaged in this
Organisation as____________________________________ with effect from ____________________________

Human Resources

POSTAL ADDRESS FORM

1. Name in full __________SHREYA ASHOK JAIN

2. Designation __________CLINICAL CONTENT ANALYST 3. Divison______ PUNE

4. Present Postal 5. Permanent Address (Native)

Address (Local) 54/B3, DAMODAR VILLA ,KOTHRUD, PUNE 411038 ASHOK TIKAMCHAND JAIN, NEAR BHAJISATH P
______________________________ 443404
____________________________________ ______________________________
____________________________________ ______________________________

6. Can you be contacted by phone. _______________________

if so, phone / Mobile Number

7. Email Address jain49773@gmail.com

Date: 17/10/2023 Signature of the Employee

Note : In case any change in the above particulars takes place, kindly make it a point to inform postively within 48 hours to the HR Departm
(Please take a printout on Joining at Cotiviti India and hand the document to HR Team with your signature)
Limited
ORT
Date : 17/10/2023
Place: Pune

Signature of Employee: Shreya A Jain

ONLY

S FORM

JAIN, NEAR BHAJISATH P.O, MARWADI GALLU NANDURA, BULDANA,MAHARASHTRA

___________
___________

9096118345

Shreya A. Jain
48 hours to the HR Department.
 GROUP MEDICLAIM PROPOSAL
EMPLOYEE'S / MEMBER'S PERSONAL STATEMENT FORM
(To be completed by each Employe / Members in respect of himself / herself and his / her eligibile family members proposed to be covered )

1. Details of Employees / Members including Family members proposed for Insurance:

S.No Name of Employee / Member and Date Of Birth Relationship to the Details of any knowledge of any possible existence or presence
Eligible family members Employee / Member or any ailment sickness or injury which may require
(Spouse / 2 Childred / Father / Mother) Gender Occupation medical attension in immediate future and / or details
Date Month Year
Subject to Four members including self. of any ailment, sickness, or injury which had been
treated during the preecding 12 months.
1 SHREYA ASHOK JAIN 16 Jul 1995 Female doctor Self
2 ASHOK TIKAMCHAND JAIN 27 Jul 1968 Male Bussinessman Employee Father
3 SADHANA ASHOK JAIN 27 Apr 1969 Female Housewife Employee Mother
4 Employee Spouse
5 Child 1
6 Child 2

1 Are you suffering / suffered from Diabetics / Hypertension / Chest Pain or Coconary insufficiency or Hyocardial Infection ? If so complete the annexed Questionaire's.

2 Residential Address of the Employee / Member :

3 a) Name and Address of Family doctor, including telephone number, if any:

________________________________________________________________________________________________________
________________________________________ Pin code _________________ Telephone No: ____________________

b) Doctors Registration Number:………………… State / U ……………………………..

All the statements made above and the answers given on my behalf of the family members are true and correct to the best of my knowledge and behalf. I have disclosed all particulars
materials to the best. It is hereby understood and agreed that the statement, answers and particulars are basis on which the insurance is being granted. If
after the insurance is effected, it is found that the statements, answers on particulars are incorrect or untrue in any respects the company shall have the
liability under this insurance in respect of myself and my family members proposed for insurance.

Place:PUNE
Shreya A. Jain
Date: 17/10/23 Signature of the Employee / Member for himself / herself
And / or on behalf of other family members to be covered.