NOMINATION FORM

GROUP-TERM LIFE INSURANCE COVER (YRTA)

Policy No: Plan: Group Term Life Cover

Policy Holder: EXIDE Life Insurance Co Ltd. Insurer: EXIDE Life Insurance Co Ltd.

I hereby request EXIDE Life Insurance Company to consider my nomination for Group Term Life Insurance as below:

Sl No Nominee Name Date of birth Relationship with No % of Sum Assure Guardian / Address
minee d Allotment

Date : .......................................

Place : .......................................

*Signature of the Employee: