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  • Mediclaim PVC Form

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    rickyarya2000
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    This document is a private medical insurance enrollment form that allows the employee to choose from four coverage options: individual only, self and family, self and family plus parents/in-laws, or self plus parents/in-laws only. The employee provides their name, employee code, contact information, and selects the desired coverage option by checking a box and filling in names and dates of birth for all covered individuals.

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    Mediclaim pvc Form

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    This document is a private medical insurance enrollment form that allows the employee to choose from four coverage options: individual only, self and family, self and family plus parents/in-laws, or self plus parents/in-laws only. The employee provides their name, employee code, contact information, and selects the desired coverage option by checking a box and filling in names and dates of birth for all covered individuals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    11 views1 page

    Mediclaim PVC Form

    Uploaded by

    rickyarya2000
    This document is a private medical insurance enrollment form that allows the employee to choose from four coverage options: individual only, self and family, self and family plus parents/in-laws, or self plus parents/in-laws only. The employee provides their name, employee code, contact information, and selects the desired coverage option by checking a box and filling in names and dates of birth for all covered individuals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Private Medical Insurance Scheme Enrollment Form

    Name: …………………………………………………………………..

    Employee Code: ………………………………………………………

    Contact Mobile / CUG No…………………………………………….

    Please refer to the Guidelines for premium details for each option. Please tick the box against the option that you would like to
    choose.

    For - Option 1 - Individual Policy

    Sl. No Name of Self Relationship Date of Birth

    Self

    For - Option 2 - Self + Spouse + Two children

    Sl. No Name Relationship Date of Birth

    Self

    Spouse

    Son / Daughter

    Son / Daughter

    For - Option 3 - Self + Spouse + Two children + Two Dependent Parents/In-Laws

    Sl. No Name Relationship Date of Birth

    Self

    Spouse

    Son / Daughter

    Son / Daughter

    Father / Father-in-Law

    Mother/ Mother-in-Law

    For - Option 4 - Self + Two Dependent Parents / In-Laws

    Sl. No Name Relationship Date of Birth


    Self

    Father / Father-in-Law

    Mother/ Mother-in-Law

    Signature: ……………………………………

    Date: ……………………………………………….

    · Note : You can choose only one from the available option

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