Establishment Nomination and Declaration Form

You can nominate the people you would like to be considered as beneficiaries for receiving any benefit
payable in the event of your death by completing this nomination form.

1. Name
2 Father’s / Husband’s Name
3 Date of Birth
4 Sex
5 Marital Status
6 Address
Permanent
Temporary

I hereby nominate the persons mentioned below, who are members of my family, to receive the Salary
amount / F&F settlement / Insurance benefits and any other benefit which may be granted by the Company,
in the event of my death.

S.no. Name of the Address Nominee’s DOB Share (%)

nominee/nominee relationship with
s the member

1 2 3 4 5

Dated Signature/ thumb impression

of the employee