Nomination form for Life Insurance and Personal Accident Insurance Cover

UID: e18456

Name of the Member: SABAIRRAJAN M

Permanent Address: NEW NO: 136, OLD NO: 55, SOUTH WEST BOAG ROAD, TNAGAR, CHENNAI 17

Email Address: SABARIRAJANM@HOTMAIL.COM

Contact Number:9941875354

Name of Entity: BNP Paribas India Solutions

Details of Nominee for Life Insurance Cover:

Full address
Sr. Name of the Proportion % by which
Relationship * Date of birth Age of the
No. nominee amount is to be shared
Nominee
1 KEISHNAVENI MOTHER 09th JUNE 1965 56 50% NEW NO:
136, OLD NO:
55, SOUTH
WEST BOAG
ROAD,
TNAGAR,
CHENNAI 17

Details of Nominee for Personal Accident Insurance Cover:

Full address
Sr. Name of the Proportion % by which
Relationship * Date of birth Age of the
No. nominee amount is to be shared
Nominee
1 JEYASREE WIFE 28th NOV 1995 25 50% NEW NO:
136, OLD NO:
55, SOUTH
WEST BOAG
ROAD,
TNAGAR,
CHENNAI 17

*includes spouse, mother, father, children, brother, sister

Details of Guardian for Life Insurance and Personal Accident Insurance Cover, in case nominee is a minor:

Sr. Name of the Address of the Relationship *

Date of birth Age
No. Guardian Guardian

*includes spouse, mother, father, brother, sister

I, member named hereinabove, declare that this appointment of Beneficiary/ies/Nominee/s made herein shall
have the effect of my revoking the appointment of Beneficiary/ies/Nominee/s made by me earlier.
Signed at __Chennai_________ this _05th________ day of _july___2021

(Signature of Member/Employee)
Name: Sabarirajan m
Place: Chennai
Date: 05th July 2021

Signature of Authorized Signatory

For Self and Member of BNP Paribas Group Term Life Insurance and Personal Accident Insurance Cover

Place:
Date:

NOTE:

An Appointment of Beneficiary/Nominee made by the Member may be changed at any time, after giving a
written notice to the Authorized Signatory of his intention to do so. If the Nominee predeceases the Member
(Employee), the interest of the Nominee shall revert to the Member (Employee) or his estate.

The appointment of Beneficiary/Nominee or any change thereof made from time to time shall take effect to the
extent it is valid on the date on which it is received by the Authorized Signatory.