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13) Cn Llle Assurec s :e2i: 3:3-1:e sna oi lne
Sum Assured
stiB!lated prean.Lr i?.':e',1 Terrr,
i-{iae6 rr il-€6 ilris* ql fri; sfi:}:; t::a ai qtl :g d er<rrin verd qrl}o ial?trdf 3{qfl w
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To whon] Sum Assured Payable
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The proposer or his Assigns oi I lor ll nees under Section 39 of the I nsurance Act, 1 938
or pioving Executors or Administration or other Legal Representatives vuho shotrld
iake oui representation to his Eslate or limited lo the moneys payable under this Policy
lrom any Ccud of any State or Territory of the. Union of India'

riftw1or'-r ir'i irrli) itulRr nfts ifitil 11mr'i dt t-illt rr rI ssd $ Onor o'i 1q tn ao
i)ayrrent or Previous death of the Life Assured
Percd during.which premium payabie Till the stipulatecj date of Last it
OCt i fiqko fil} qi I, IL
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Dates vr'hen prerniunr payable 0n the stiDulated due dalein
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Special Provisions

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TUORKS:
PODDAR NAGAR, G.T. ROAD, JUGIANA,

PI ) ) ' LUDHTANA- 141017 (PUNJAB)


Tel.: 0161 - 2511556 - 60
Fax: 91-161-2511566
TYRES LIMITED E-mail: ptl.ludhiana@bedrocktyres.com
Websit6: www.bedrocktyres.com
CIN: U251 00MH1981 P1C023895

Member & Emplover


Joint Declaration of EPF bv the

To$
The Regional FF Commissioner' +

......SIIAM NAGAR LI]DHIANA


herewith correct details with aforesaid
TYres Limited, furnishing below
VIPiN KUMAR emPloYee Poddar
establishment:-
UAN 100027120197
Establishment Code: ' ..LDLDHo01062800038345
Gorrect Wrong Entry in my A/C
Particulars
a
N.{}1E
LAKHAN SAU LAKHAN SAH
Father 11u5[snd \ame
.t
EPF"/EPS Account No'

LA\ \umber
Date of Birth
(DD/MM/YYYY)
Date of Left
(DD/MM/YYYY)
of ADIIAAR CARD
coPY
I am enclosing herewith attested (if required) under
to make the necessarY changes in your records
Therefore, You are requested

information to me. An earlyactioninthisregardwillbehightyappreciated.


Encl.: As above
Yours faithfullY' fOT FUDDARTTRES
Name & Signature of the 'n1:*r".)4
,u^w* kt Iqt
oi
$6X1gai iP':t;' fir
Signature of AO(C) with

(AN ISO 9001:2015 CERTIFIED COMPANY)

FBCDRO(T REGo. & HEAD OFFICE: 5.D, COURT CHAMBERS, 35, NEW MARINE LINES, MUMBAI - /100 tzii.
ADi|iI{ISTRAITVE OFFICE: GB, COURT CHAMBERS, 35, NEW MARINE LINES, MUMBAI - 400 020.
1el.:Q222220 6554.2200 3529, Fax: 91-2?-2208 0745, e-mall: ptl.mumbai@b6drocKyEs.com

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