EMPLOYEES FAMILY DETAILS FOR MEDICLAIM

POLICIES
1. Name of the Employee :
. De!"#$at"o$ :
%. Employee No. :
&. '(o!! Mo$thly Sala(y :
). A#e * Date of +"(th :
Details of Dependents
Sl.
No.
Name of the Depe$,e$t 'e$,e( Relat"o$!h"p Date of
+"(th
A#e
Spo-!e
Ch"l, 1
Ch"l,
Fathe(
Mothe(
Signature of the Employee