Application for Enrolment of Membership for SAIL Mediclaim Scheme

(for the period 11th July, 2019 – 10th July, 2020)

Employee Details
Name of Employee SANTANU GUHA Personnel No. 94531 / F001089
Unit from where retired IISCO Steel Plant Place of Last Posting Elect. Maint. Designation last held Dy. Mgr.
Date of Separation KOLKATA CHENNAI DELHI BHILAI DURGAPUR
3 0 0 9 2 0 2 0 Claim Centre
(only for
D D M M Y Y Y Y ROURKELA BOKARO SALEM ASANSOL
Enrolment)

Name of Member SANTANU GUHA

Date of Birth 0 1 1 0 1 9 6 0 MIN Gender M
D D M M Y Y Y Y No. (M/F)
Name of Spouse RASHNA GUHA
Date of Birth 0 7 0 3 1 9 6 4 MIN Gender F Please affix recent Please affix recent
No. (M/F) photograph of photograph of spouse
D D M M Y Y Y Y
member
Address Road No. 6, Bungalow No. 20, River Side Town Ship,
PO. : Burnpur, Dist. : Paschim Bardhaman,
West Bengal

Pin Code 7 1 3 3 2 5 Phone 8348895214 / 9732206615 Cell 9 4 3 4 7 7 6 1 2 2

Email ID guhask.sailisp@gmail.com / rashna.guha@gmail.com
Aadhar No. (Self) 6986 7043 7818 Aadhar No.(Spouse) 7211 0458 5827
Date of Enrolment Number of Members Two (2) SANTANU GUHA
(for fresh enrolments only) D D M M Y Y Y Y RASHNA GUHA
Premium for Employee(Rs.) Premium for Spouse(Rs.) Total Premium(Rs.)
Nominee of Employee Relation with Employee
RATNABALI GUHA Daughter
Nominee of Spouse Relation with Spouse
ECS Details Employee Spouse
Name of Account Holder SANTANU GUHA RASHNA GUHA
Name of Bank The Burdwan Central Co-operative Bank Ltd.
Branch Name Burnpur
Branch Address The Burdwan Central Co-operative Bank Ltd., Branch : Burnpur, Trevani More AMC Bulding,
PO : Burnpur, Dist. : Paschim Bardhaman, West Bengal, Pin Code : 713325
Type of Account (tick) Savings Bank Current Deposit
Member Account No. 1 2 4 MICR Code
Spouse Account No. MICR Code
IFSC Code Member MIN No. Member
IFSC Code Spouse MIN No. Spouse

Signature of Member Signature of Spouse

Payment Details
Cheque / DD / Cheque No. : Amount (Rs.)
Challan No/ Drawee Bank THE BURDWAN CENTRAL CO-OPERATIVE BGANK LTD.
Salary ECS
Members to Note
Enclosures: (1) One copy of Aadhar Card each for the member & spouse; (2) One cancelled cheque with Name & P.No. at the back.
Intimation : (1) Pre-planned hospitalization - 48 hours in advance; (2) Emergency - within 24 hrs from the time of admission.
Claim Submission : (1) IPD - Within 30 days from the date of discharge; (2) Post-Hospitalization – within 30 days after completion of treatment period of
60 days; (3) OPD - When expenses exceed Rs.2000/- per person per policy period or within 90 days from the date of treatment, whichever is earlier.
Cappings/Ceilings : Members to apprise themselves regarding Cappings/Ceilings before availing mediclaim facility, from the SAIL Website / Mediclaim
Booklet.
THE ABOVE TIME LIMITS TO BE STRICTLY ADHERED TO, SO THAT THE CLAIMS ARE NOT REJECTED.
The deviation raised by M/s Nangawal Industries is correct. Actual it will be Class 2 and Table 2 asper IS: 7098‐1
(part 1)/1988, Clause No. 8.1 of construction for XLPE insulated and PVC sheathed cable. Rectification in both
Material Description and TS is required.
So let us please arrange to rectify the problem.

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