Note:- Red cells are complusary field.

Suzlon Group of Companies

Declaration For Mediclaim Insurance

Please give details of Dependents. No changes will be accepted later.

Emp No Full Name RELATIONSHI GENDER P DOB MM/DD/YY Age GRADE SUM INSURED COMPANY LOCATION Name of Local HR HR e-mail Id santosh.rout@synefra.com

52020026

Digvijay s shinde Anjali shinde Ratnamala S shinde Shahajirao L Shinde

Self Spouse Child1 Child2 Mother Father

Male Female Female Male

03/15/83 9-Jun-09 05/05/58 06/30/48

30 3 54 64

M5

Synefra Engg & Const Ltd

pune

santosh rout

If the Employee wishes to add 4th and 5th non-earning dependant member ( children or parents ONLY )in the policy, then the Premium of these non-earning dependents will be paid separately by the Employee. Please Note: The additional non -earning dependants are declared in this declaration ONLY.
Note : Childern are considered only till age of 25 years of age.Dependant Parents are covered at entry age of 80 years of age. No Sister or Brothers can be covered. Note : If the declared dependant is identified as an independent earning member than, it is likely that such claims are likely to be repudiated Declaration By Employee: I confirm that the above mentioned information is true and correct to the best of my knowledge and the dependents mentioned above are non earning members in my family.

Premium chart for each 4th and 5th non-earning dependent addition
Grade Sum Insured In INR Premium in INR
M2,M1,M0,T1 50,000 1,149 M3, M4 75,000 1,522 M5 125,000 2,118 M6,S1 200,000 3,706 S2 300,000 4,970 S3,S4,S5 600,000 6,649 Director-Do 1,000,000 13,570