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ANNEXURE - I (For serving members)

JD&DH (Finance)
C-DAC (T)
Ref: Circular dated 17th March 2018
Sir,
I wish to be covered under Centre’s Group Personal Accident Insurance Policy for the year
2018-2019 for which, my details are as follows:
1. Name (in Capital Letters) :
2. Staff No (mandatory) :
3. Extension No & Mobile No :
4. Date of Birth :
5. Designation / Grade :
6. Department/Section :
7. Monthly Gross Salary (Basic + DA+
HRA + TA or Consolidated Amount:

8. Coverage requested 1) Death only : Table I : Rs ……….. lakhs


2) Death/ PTD : Table I (a): Rs ……….. lakhs
(For member) 3) Death/ PTD / PPD : Table II : Rs ………... lakhs
4) Death/PTD/PPD / TTD : Table III : Rs……….... lakhs
(Max. sum insured under Table III is limited to Rs. 5 lacs.)
9. Details of Spouse:
a) Name :
b) Date of Birth :
c) If employed (Yes / No) :
d) Name of office / organization :
e) Monthly Gross Salary :
10. Details of Dependent children: (should be unemployed)
Particulars Child 1 Child 2 Child 3
a) Name
b) Date of birth
a) Age:
(should not be below 5 yrs)
11. Details of Dependent Parents:
Particulars
a) Name
b) Date of birth
b) Age

12. Coverage requested for spouse and Dependent Children:

(i) Table I a) Spouse : Rs …………….lakhs


b) Dependent Children : (1) Rs……………..lakhs
(2) Rs……………..lakhs
(3) Rs……………..lakhs
(ii) Table I (a) a) Spouse : Rs …………….lakhs
b) Dependent Children : (1) Rs……………..lakhs
(2) Rs……………..lakhs
(3) Rs……………..lakhs

(iii) Table II a) Spouse : Rs …………….lakhs


b) Dependent children : (1) Rs …………….lakhs
(2) Rs …………….lakhs
(3) Rs …………….lakhs
(iv)Table III a) Spouse : Rs …………….lakhs
(If employed, max sum insured limited Rs.5 lacs)
(Not applicable for Unemployed/selfemployed)
13. Coverage requested for Dependent Parents:
(i) Table I (a) a) Father : Rs………………lakhs
b) Mother : Rs………………lakhs
(Maximum sum insured limited to Rs.3 lakhs per parent)
DECLARATION
1. I hereby authorize that the premium payable may be recovered from my salary in 10 equal
installments starting from April 2018.

2. I, ……………………………………do hereby assign the benefits under the policy as


mentioned below and his/her receipt shall be in full and final discharge to the company.

In the event of Name of Nominee Nominee’s


death of: relationship with
staff member
1) Self
2) Spouse
3) Children
4) Parents
5) Self, Spouse, Children & Parents
3. I, ………………………do hereby agree that on my leaving CDAC before full recovery of
premium from my salary, the balance amount can be deducted in one lump sum.

4. I,…………………………do hereby declare that the details given above are genuine and
correct in terms of the spirit and objective of the policy covered, and documents to prove the
same shall be produced as and when required for this purpose.

Dated at Trivandrum this …………….day of …………………….. 2018.

Shri/Smt.…………………………….
(Signature of the member) Witness: (Name, signature with date)