Staple passport

size photograph
NATIONAL INSTITUTE OF TECHNOLOGY
WARANGAL

HEALTH AND ACCIDENT INSURANCE FORM

FOR STUDENTS OF NIT WARANGAL

(To be submitted by all the students at the time of registration)

1. Name of the Student: ………………………………………………………………..

(In Block Letters)

2. Programme of study: ……………………………

( B.Tech/M.Tech/MBA/M.Sc(Tech)/M.Sc.)

3. Branch / Specialisation: ………………………………………………………………

4. Date of Birth(DD/MM/YYYY):………………………………………………..

3. Hostel Room No(In case of Hosteller)::

4. Permanent Address:…………………………………………………………………….
……………………………………………………………………..
……………………………………………………………………..
…………………………………………………………………….

5. Name of the Parent /Guardian:…………………………………………………………

6. Name of the Nominee: …….….. ………………………………………………….

(Should be other than the name of Parent
/Guardian mentioned above):

7. Relationship of the nominee with the student:………………………………………

DECLARATION:
I hereby declare that information furnished above are true and correct to my knowledge
and belief.

Place:

Date: SIGNATURE OF THE STUDENT