FEEDBACK INFRA PVT. LTD.

DECLARATION

The following members of my family may be included in the list of ‘Family Members’
for the purposes of claiming Mediclaim and for dependants coverage (Spouse & children
only) under the Group Mediclaim Policy:

S.No. NAME RELATION AGE DATE OF BIRTH

1.

2.

3.

4.

Nominee for personal accident insurance & Gratuity

Name Relation Age Date of Birth

___________________________________
Employee Signature

Name :______________________________
Designation :______________________________
Division :______________________________
 (OPTIONAL)

DECLARATION FOR INCLUSION OF PARENT’S NAME

Please include my parent’s name in the group medicalim policy and I will bear the
premium for the said policy. Details are given below

S.No. NAME RELATION AGE DATE OF BIRTH

1.

2.