TEMPLATE FOR DATA COLLECTION FOR THE MEDICLAIM INSURANCE POLICY

Enter data in specified format only and send to veritas.support@anviti.in

Sr. No. Employee ID Name Of Insured Relation

1 SELF

2 SPOUSE
3 CHILD 1
4 CHILD 2
5 FATHER
6 MOTHER
Office Location :
Note: Any Duplication in data is not allowed (Except for Employee & Spouse), member can be enrolled in the policy only o
providing the data
1. In case Husband+Wife both are working in Veritas, both can cover each other as spouse
2. In case Husband+Wife both are working in Veritas, do not enroll your children twice, in case of one child any one can en
each parent can enroll one child.
3. Incase two siblings are working with Veritas, do not enroll your parents twice. Either any one sibling can enrol both pare
two siblings.
4. Employees can cover their parents Only
Guidelines for filling the template

1. Please fill in the Name of Insured against the Relation with the employee, the coverage is 1 + 5 I.e the employee and u
2. Family definition : Employee + Spouse + Child 1 + Child 2 + Parents
3. Marital status, Date of Joining the Company, Entity is required of the employee only.
4. Siblings are not eligible as per the Family definition of the Mediclaim Insurance Policy.
5. Please make sure that the date should be in the DD-MMM-YY format ie.(Date-Month-Year -
6. Employees can not alter the dependent declaration once enrolled in the Policy in the mid of the policy year.
ICY

Date of Birth Gender Occupation Marital Status Date of Joining

(DD-MMM-YY) M/F Yes / No (DD-MMM-YY)

Date of Marriage
(DD-MMM-YY)

mber can be enrolled in the policy only once. Kindly check the below conditions before

as spouse
twice, in case of one child any one can enroll under his/her policy and in case of two children

Either any one sibling can enrol both parents or two parents can be covered seperately under

coverage is 1 + 5 I.e the employee and upto any five specified members of the family.

only.
Policy.
Month-Year - 01-Jan-2000) .
n the mid of the policy year.