ARMSTRONG WORLD INDUSTRIES (INDIA) PVT.

LTD

JOINING REPORT

1 : RAWAT SURAJ
NAME OF THE EMPLOYEE
2 : DHARAMSINGH RAWAT
FATHER’S / HUSBAND’S NAME
3 : SHRI.DHARAMSINGH RAWAT , FLAT
ADDRESS NO.604 , BUILDING NO.12 , SILVER PARK ,
OPP. SAIBABA MANDIR , MIRAROAD [E],
MUMBAI - 401107

4 PAN No : AMPIR0809C
5 : +919819154872 / 7506255704
TELEPHONE NO
6 : 28/04/1980
DATE OF BIRTH
7 : MANAGER VENDOR QUALITY
DESIGNATION
8 : MS GODREJ AND BOYCE , PL-17 SSD
LAST EMPLOYMENT WITH DIVISION
9 DESIGNATION ON THE LAST : SR.MANAGER QUALITY ASSURANCE
EMPLOYMENT
10 NO OF YEARS SERVICE IN THE LAST : 8 YEARS & 9 MONTHS
EMPLOYMENT
11 TOTAL NO OF YEAR’S EXPERINCCE : 14 YEARS
BEFORE JOINING ARMSTRONG
WORLD INDS (I) LTD
12 : BE – PRODUCTION ENGINEERING
EDUCATION / QUALIFICATION
13 WHETHER A MEMBER OF- :
YES
PROVIDENT FUND
14 FAMILY PENSION SCHEME : YES

15 SUPERANNUATION : NO

16 INCOME TAX DEDUCTION :

CERTIFICATE FROM LAST ENCLOSED / NOT ENCLOSED
EMPLOYER

17 DATE OF JOINING ARMSTRONG : 27 NOVEMBER 2017

WORLD INDUSTRIES INDIA (PVT)
LTD.
18 I HERBY CONFIRM THAT I HAVE : RELEIVED ON 10 OCTOBER 2017
BEEN RELEIVED BY MY LAST
EMPLOYMENT W.E.F.

...................... ……………..
DEPT. HEAD EMPLOYEE
1
 FORM OF APPOINTMENT OF BENEFICIARY

Group Insurance Scheme

To,

ARMSTRONG WORLD INDUSTRIES (INDIA) PVT. LTD

B2, G01, Marathon Innova
Near Peninsula Corporate Park
Lower Parel (W)
Mumbai 400 013

Dear Sirs,

I, RAWAT SURAJ DHARAMSINGH an insured Member of the ARMSTRONG WORLD

INDUSTRIES (INDIA) PVT. LTD . Group Insurance Scheme hereby appoint in terms of Rule
No.14 headed, “APPOINTMENT OF BENEFICIARY” of the Rules governing the Scheme, my
(relationship) …WIFE. named……MRS. SUSHMA SURAJ RAWAT.. aged…33... and whose
address is… FLAT NO.604 , BUILDING NO.12 , SILVER PARK , OPP. SAIBABA MANDIR ,
MIRAROAD [E], MUMBAI -401107. as the person to be the Beneficiary to whom the moneys
payable in terms of the Rules of the Scheme shall be paid in the event of the my death.

Signed at Andheri , this 27 day of November 2017.

________________________

Signature of Insured Member

WITNESSED BY :

1 i) Signature

ii) Name

iii) Address

2 i) Signature

ii) Name

iii) Address

Page 1

2
 FORM OF APPOINTMENT OF BENEFICIARY
(Nomination)
Employees’ Group Gratuity –cum-life Assurance Scheme

The Trustees ,
ARMSTRONG WORLD INDUSTRIES (INDIA) PVT. LTD
Employees Group Gratuity- cum- Life Assurance Scheme.

Dear Sirs,

I RAWAT SURAJ DHARAMSINGH a member of ARMSTRONG WORLD INDUSTRIES

(INDIA) PVT. LTD Employees’ Group Gratuity Scheme hereby agree to abide by the rules of the said
scheme and do also hereby appoint in terms of rule 18 of the rules of the beneficiary/ beneficiaries/
Nominee/s mentioned here under to receive the benefits, payable under the scheme. In the event of
my death before the amount becomes payable has not been paid.

I hereby direct that the benefits under the scheme, payable in respect of me, shall be paid to the said
beneficiary/ beneficiaries/ Nominee/s in proportion indicated against there respective names as given
below:-

Sr. Name in full with full address Relationship with Age of Proportion by which
No. of Nominee/s Beneficiary/ies the Member Nominee/s gratuity (total
(Employee) Beneficiary/ies benefits) will be
shared by each
nominee/beneficiary
1

MRS. SUSHMA SURAJ WIFE 33 100%

RAWAT

I hereby certify that the person(s) mentioned hereinabove is/are my wife/children/lawfully adopted
child/dependent parents/husband.

I hereby declare that I have no family and should I acquire family hereafter the appointment of
Beneficiary/ Nominee should be deemed as cancelled.

My father/mother/parents/sister(s)/minor brother(s) is/ are not dependent on me.

My husband’s father/parents is/are not dependent on me.

I also declare that this appointment of Beneficiary/ies/ Nominee/s made herein shall have the effect of
my revoking the appointment of Beneficiary/ies/ Nominee/s made by me earlier.

3
 Page 2
FORM OF APPOINTMENT OF BENEFICIARY
(Nomination)
Employees’ Group Gratuity –cum-life Assurance Scheme

I give below my particulars about myself :

1. Full Name; ___RAWAT SURAJ DHARAMSINGH__________________

2. Sex :____MALE 3. Religion: ___HINDU________________

4. Father’s name: __MR. DHARAM SINGH RAWAT .

5. Husband’s Name: (for married women only) ; _____-________________

6. Marital Status: __MARRIED .

(Whether married, unmarried, widow or widower)

7. Date of birth: 28/04/198 .

8. Permanent address: SHRI.DHARAMSINGH RAWAT , FLAT NO.604 ,

BUILDING NO.12 , SILVER PARK ,
OPP. SAIBABA MANDIR , MIRAROAD [E],
MUMBAI , PIN CODE – 401107.

____________________ Signed at _ANDHERI , this 27TH day of _NOVEMBER 2017

(pls. sign here)

Two witnesses to the sign. Address Signature

Name. 1. _______________ __________________________ _______________

2. _______________ ___________________________ _______________

Certified that the above appointment of Beneficiary/Nominee has been signed by Shri / Shrimati
RAWAT SURAJ DHARAMSINGH before me after he/she has read the entries, the entries have
been read to him/her by me and that the said appointment of Beneficiary/Nominee is recorded
under the Scheme on _____________________

______________________________
Signature of Trustee/s

For self and Co- Trustees of________

____________________________
Group Gratuity Scheme.

Place:

Date:

4
 Page 3

FORM OF APPOINTMENT OF BENEFICIARY

(Nomination)
Employees’ Group Gratuity –cum-life Assurance Scheme

NOTE:

1. Where an employee member has a family at the time of appointing a Beneficiary / Nominee,
the nomination should be made in favour of members of his family only. Any nomination
made by such employee in favour of any other person not belonging to his family shall be
invalid.

2. An appointment of Beneficiary / Nominee made by the member may be changed at any time,
after giving a written notice to the Trustees of his intention to do so. In the nominee
predeceases, the member (Employee), the interest of the Nominee shall revert to the member
(Employee) or his estate.

3. The appointment of Beneficiary / Nominee or any change thereof, made from time to time,
shall take effect to the extent it is valid on the date of on which it is received by the Trustees.

4. For the purpose of the scheme, “Family” means Members (Employee’s) spouse, legitimate
children / step children, parents, sisters and minor brothers dependent upon him.

5
 Page 1

Group Mediclaim Proposal

EMPLOYEE’S/MEMBER’S / PERSONAL STATEMENT FORM

(To be completed by each Employee/Member in respect of himself/herself and his/her eligible family members
proposed to be covered)

1. 1. Details of Employees/Members including family members proposed for insurance:

Sr. Name of Employee/Member Date of Sex Occupation Relationship to Monthly Details of any
No. & eligible family members Birth the Income knowledge of any
Employee/Mem positive existence or
ber presence of any
ailment, sickness or
injury which may
require medical
attention in
immediate future
and/or details of any
ailment, sickness or
injury which had
been treated during
the preceding 12
months
a. MR.SURAJ 28/04/1 MALE SERVIC SELF
DHARAMSINH 980 E
RAWAT
b. MR, 17/03/1 MALE RETIRE FATHER NILL NILL
DHARAMSINGH 945 D
RAWAT
c. MRS. BIMLA 03/09/1 FEMA HOUSE MOTHER NILL SUGAR ,BP
DHARAMSINGH 959 LE WIFE
RAWAT
d. MRS.SUSHMA 02/10/1 FEMA HOUSE WIFE NILL
SURAJ RAWAT 984 LE WIFE
e. MISS. SAACHI 13/09/2 FEMA STUDY DAUGHTE NILL
SURAJ RAWAT 012 LE R

f. MASTER SAMRIDH 07/10/2 MALE STUDY SON NILL

SURAJ RAWAT 014