UNIVERSITY OF RAJASTHAN, JAIPUR

Affix New
PERFORMA FOR STUDENT GROUP INSURANCE Passport Size
Photograph
SESSION – 2024-2025

College/Department/Centre:

Name of Student Date of Class with Mother’ Name/ Present Address Mobile Number
Birth Sec7on Father’s Name

Name of Nominee & Address Rela7on

Signature of Nominee Signature of Student

UNIVERSITY OF RAJASTHAN, JAIPUR

Affix New
PERFORMA FOR STUDENT GROUP INSURANCE Passport Size
Photograph
SESSION – 2024-2025

College/Department/Centre:

Name of Student Date of Class with Mother’ Name/ Present Address Mobile Number
Birth Sec7on Father’s Name

Name of Nominee & Address Rela7on

Signature of Nominee Signature of Student