DETAILS OF DEPENDENT FAMILY MEMBERS

Relationship
Date of Birth with the
Sl. No. Name Gender Occupation Place of Residence
employee

I Certify that:

1 I have read the eligibility conditions with regards to declaration of dependants as defined in MEDICAL ATTENDANCE AND TREATMENT RULES of PDIL and
related circulars issued from time to time by the management.
2 I declare the above named family members, as my dependent, for availing the group Mediclaim facility.
3 My parents reside with me and are wholly dependent on me.
4 My spouse is working in__________________, however, we opt to avail the Indoor Medical Treatment facility provided by PDIL. A certificate issues by my
spouse’s employer certifying non-availment of medical facility from them is enclosed.
5 My spouse is not working.

Signature _________________________
Name _________________________
Employee No. _________________________
Address ________________________
Date

Forwarded by
HOD

Date
Rubber Stamp

Note: HOD(P&A) shall be HOD for all ex. employees at all centres. The above declaration is purely for the purpose of taking Group Mediclaim Policy
and it will not change any status in the present medical dependency declaration.