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    antay.halder19
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    The document provides information for employees to add dependents to their company's hospitalization insurance policy. Employees can cover their spouse and up to two dependent children under age 25 at no extra premium. Married female employees can also include one set of parents (maximum two people) with a prorated premium deduction. The insurance policy cycle runs from November 1 to October 31. Employees must provide details like dependent name, gender, date of birth, and relationship to be covered. Additional premium amounts are listed for grades of employees to cover parents under the policy's consolidated floater sums insured of Rs. 6 lakhs, Rs. 4 lakhs, or Rs. 2 lakhs depending on the employee grade.

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    The document provides information for employees to add dependents to their company's hospitalization insurance policy. Employees can cover their spouse and up to two dependent children under age 25 at no extra premium. Married female employees can also include one set of parents (maximum two people) with a prorated premium deduction. The insurance policy cycle runs from November 1 to October 31. Employees must provide details like dependent name, gender, date of birth, and relationship to be covered. Additional premium amounts are listed for grades of employees to cover parents under the policy's consolidated floater sums insured of Rs. 6 lakhs, Rs. 4 lakhs, or Rs. 2 lakhs depending on the employee grade.

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    Download as doc, pdf, or txt
    9 views2 pages

    Medical Form

    Uploaded by

    antay.halder19
    The document provides information for employees to add dependents to their company's hospitalization insurance policy. Employees can cover their spouse and up to two dependent children under age 25 at no extra premium. Married female employees can also include one set of parents (maximum two people) with a prorated premium deduction. The insurance policy cycle runs from November 1 to October 31. Employees must provide details like dependent name, gender, date of birth, and relationship to be covered. Additional premium amounts are listed for grades of employees to cover parents under the policy's consolidated floater sums insured of Rs. 6 lakhs, Rs. 4 lakhs, or Rs. 2 lakhs depending on the employee grade.

    Copyright:

    © All Rights Reserved
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    of 2

    MEDICAL DEPENDENT DATA

    (To be filled by employee for each of the dependents that he chooses to cover under the hospitalization Insurance. As part of the
    Company Policy Employee can add his Spouse + 2 dependent children upto the age of 25 years at no extra premium. Incase of married
    female employees, they may include their Mother-In-Law & Father-In-Law. The employee cannot cover more than 1 set of parents
    (maximum of 2 persons). Deduction will be done on Prorata basis for dependent parents, if employee covers his/her parents.
    Hospitalisation Policy cycle : 1st November to 31st October

    TO BE COVERED
    Dependent Sr No Dependent Name Gender
    Date of Birth Relation
    IN HEALTH
    (DD.MM.YYYY) INSURANCE
    YES / NO

    Dependent 1

    Dependent 2

    Dependent 3

    Dependent 4

    Dependent 5

    Dependent 6
    For adding dependent parents, the charges are as highlighted below for deduction.

    Additional Premium Per Dependent Consolidated Floater Sum


    Parent P.A. Insured Per Employee Family
    Grades Premium P.A.
    Amount
    MD, President, ED, Rs. 6 Lakhs
    Rs. 16,500/-
    SVP,VP & GM
    Trainees on par with Rs. 4 Lakhs
    M2(Incl. GMR) M2 & Rs. 11,750/-
    M3
    M1, ME &Trainees on Rs. 2 Lakhs
    par with M1(Incl. MT,
    Rs. 3,363/-
    GET,ST,OT, AT) &
    Corporate

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