Employee & Family Information

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This form is provisionally collecting the information for the Group Medical Insurance Policy.

Please keep Aadhar Card Number of Self and all family members with you to fillup the form.

For Form related or correction related please contact Mr. Surender Singh 9992642789, Mr. Rajesh Kumar 9416632046

Employee of ___________ *

College

School

Name *

Designation *

Gender *

Male

Female

Date-Of-Birth *

YYYY

Mobile Number *

Aadhar Card Number *

PAN Card Number *

Email (Optional)

Address *

City *

Pin Code *

State *

Type of Employment

Do you have personal insurance (medical) policy ? *

Yes

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