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cqd fi $ (Sq) -2lFoRM GG(cA) - 2 sT6 sq<IJId-s{ /GROUP GRATUTTY SCHEME

pOLtCy cc4cAy_ crr dfrrs 6. d d / (oq) /MASTER NO.

tfr/ro.

areratgo flrq s{tgtrqr ,----. 1fof '\9 la@u.*fd*nrbra


Drvrsrolr Iir{ fuIFr / IiT{ qtrgd/ MUMBAT

Corpotofion Jnrlio of 6trrJnsurorcc


ffi/Wl+oq-qrsrqai*qrn
1 2.(or) 2.lal s
(b) 3.

INTITI|ATION RETIREMENT'DEATH'LEAVING OF SERVICE ' I vEgri iiq/Nameof member 2. q\ qqRq-s<se oqio a) LIC Membership Numbet r) a-diorf,fiqio
i)-dRs Fqi6 RollNumber/ b) Salary ldntigNumber 3. ciffisdFrf,rflFri-6 Oatg Joining of SeNice

a. ftfr{frqio
Oateot Exil

4
s (s)
5(a) q
(b)

5. (of) sG'tfiri 6Rsr


(a) Cause Exit of (s) Tqqr qFd-d Tqn i6Rq(Tqn cqrqcE
TEFI. (b) ln caseof death, Cause Death(Death of Certificateto be attached)

6.

sRq{nRninq qtqiar eImd id"


for Salary the purpose of Scheme the Dateof Exit on

6.

z.

ffqqEsn c{q iq sr<rc


Total Gratuitypayable as per Rules.

7.

Rlio/oate :

Fo:o'tm g ft s6frnRi6t-dl ForSelf& Co-Trustees ot


q{6 sqqli {tq.fi

Group Gratuity Schen {slert/ signature


RH. (17) 75 Pads x 10O 6/2000

fr{/TRUSTEE

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