F-

NIa\ llrlf ll.:,11[ lortrrE (.t!n]rr,r'ri'n rcd

ll l/l : Nl1)lim(o.pc,rrivclddunirl linrl!.
Mil,u ltor,l N!\ l)tllji ll00r4

a)

yor ofierol Appoi'

t)ltr23
- oncntr! t tl. no\
wnh rcfo.rcc ro D,.nL 'f ^
ll,e ebl R r ,]tr'r
t2/t2/25
-
'u,ldr 'jtr

cu't Dcr)

lB+a"ln-\t Dt i
t? lt2/ L9
ryL)
 MAX BUPA HEALTH INSURANCE COIIJIPANY LTO.

FORI\]1 FOR AD]\NISSION UNDER COI\]IPANY [,1ED CLAIM POLICY

I :llllLX.u D lJ- Itlortg EEI

a
PraAl.V+L) ah ( ,t
I ) .

E
-l

:renrs,n }v l3!e, o rr Rness o' em

Known Med calProb ems P ndcar€ 3lkn.(n.ondtonr

Name Address & Telephone nunbar of lam v d..lor (This in'orm'l on s essent a )
 MAX BUPA HEATTH INSURANCE COMPANY I

EIvIPLOYEE INFORIVIATION SHEET

POSIT ON hDD LacAroN ftEJ

p-
DATED /lO n r.j/ a-
/4 lrtZ/
REFERfNCt -)

Narne (in BLock lellers: Sutrrame rnsl) ,afr4 /\l D+

D
o'J u
uk ?

ef3Lo>
zo )or/Qt PraceorBidh qo/+elu4-
rn ,!:^
OD
I
To1al No of dependenls
Languages Known (Spcc fy Prol.iency n Spc;k n! rleading & v,/Jillig) c_-

Educational & Professional Qualifications (State highest qualification fi6t)'

Examination Nature of courso - Main
/ Degree College/ Board Passing Subjects
lnstitution Time/corrcspondenc

LNK
)-1 1/-
|
holHi,A FU L(- 2-"1 7-9 oDts
cottl)n1-
2l l/4NDl
Ldm.l*

Any oih.r q!aliiication nol nrentioncd above

 Emplovmcnt Rccor'l lCirronologrcal ord'r)
tul..h..p.,.1{r !hecl(s) I rcq! red

Designat on & Nalure

of Work (DD/r,1M/YY)
ffii'*":x"
per month

On
On Joiilng

Fu I delarls of Existing/Lasl drawn ( l uncrnplovcd) FmolLnnents

Per nronth

S!p-.raf nuilion. G.alu lY

Any other Lle.efi ls/Perqu slles

Give name, Occupation and address oilwo referees who are nol relallons

S. No.

AJw*^'lo" vg>3
I
n.t.r"l)rrly
L' E?'o'+- b6-1414-,!-'t- 1

v lca,b'+a-
L^ft"04-4= ba "9.^-' *tq ?qg gj-
Dc,
Any known den calprob enrs / h:ndr'ps

cvc.let.ls ol..y malor .€ss / surgery / a6de't n lhe lasl { ve ve'rs

O1!q! NO
bt anv Cold of t aw'l YES
tlave vo! b.en'v' ved !n 2'v cam na! proc€ed nls r'o'v'led
ti
YES NL)
2 u evcr emba ed on .n ndependent cnle'pnse of a Persona nahrre?
li so p ease glve deta

3 Llo you lrold .n nslran@ ense wth any comparv'

ir BuPr H..hh h5uBic..o Lld,? YES

YES NO
4 Oo yo! have .nv relatves wo ing with N4ax Bupa o' t'v Mar Group Conipa'v?
li yes. Pl.ase Provlde deta s

Relationship with self

Code/ u p ovee ltr e t'

pasl Yes / No' li Yes Ple' 5e p'ovi'le Agenl lD// Ve ndor
E
Whelhcr yo! we.c assoc aled wlth l"4ar Alpa '

a.d declare th'l thc slalenr'nls drade above nre lIUe arrd thai have conce?led
hcrebv solemnlv afnrm
l:[ffi'.ili:';;l# i;.,."- ""v.iir,' "t'""" 'i"*"]'"ii " r'-o o" Iarse or naccuraie I am ]abrc 10 be
"
dismlssed summar lY
D4
Daie t?.tt2/29 Signaiure ofAPPlEanl b:ffi-
 FORM OF APPOINTIVIENT OF NOMINATION

The
'I
ruslccs
[4ax Bupa Heallh lnsurance Company Limiled Fmployees Group Gratuity

Fund Dear Srrs

0r, t#fHLi DAJ
Group Gratuily Funcl hereby agree to abde by the PuFs ot lhe sard Fund and do
aso hereby appoint
payable under
nominee/s in ierms of Rule- 18 of lhe Rulcs lnertoned hereunder to recerve lhe benefts.
payable has
the Fund. n the evelll oJ my death before the anrount beconles payable ancl having becofiling
not becn paLd

l) I hereby dlrect that the benefits under the tiund payable ln respect of nre shall be paid lo the
said Nomrnee/s in proportion ind cated againsl thelr respectrve names as given below:

Age of Proporliorl by
Sr Name ill iull wilh Iull address of Re at onship
No Nominee/s Benerclary/ies with the Nontinee/s which
l\,4ember Beneficiary/ies gratuity (Total befefits)
(Employ-.e) wll be share by each

1 ( t r () , DA-\ ( PbuA.€ 1.-r taa'/.

2.
'(Q,1tt
3

:) lhereby c.rrlriy lhal the person(s) mentofed hereinabove ls/are my wLfe /chLdren/la,14!ly
adopted ch ld/dependant parents/irtrsbaf d

l) I hercby cleclare thal I have no fanlily ancj shoLrld I acquire fam ]y hereafter the appo ntment of
Non.r .- 10 o I d.. r-u ,q. " r a l.d

4) lMy fathcrmolher/parents/slsie(s)/r inor brolher (s) is/are not deperdenl on nre

s) lvly husband s fathe/parents ls/are not dependent on me

6) I also declare that thls appoinlment of Nominee/s made herein shall have the effect of my
revoking the appointment of Nominee/s made by me earlier' Thanking you

i.) ^tYt)
(S
lr'(tlqtn
qn:lU6,6l \Lmp vlPmber oveer

lwo Wtnesses to the srgnatLrre

Sl.No Address SlgnalLrre

1 DID)t i, IML DD&J
Z.n",r
2 lu un-,tl o/- )l'.
r
NOTES:
I Picasa slrikc thai whrch s not app catrie to \,.u
.i Viilcre :rrr Erf p oyce/lr,4embcr has n iamriv::rl llte tDlc ol appointrno a NoIrnee tfe l!crnrnatton
:rhoud be mrde n l.vour of lhe [4er] b.rs l;n ly onj rny Numnatr.n nl.,d. iry sLrch L mployce in
favour of .ny .rther persofs nol be onll fg Io h s fam ly sh;r I tre rllvalid
I An spporntrnenl oi Nomnee made bythe f!4ernber can bc changed al any time after gvni:t a witten
notce 1() lhe Truslees ol his intent oJr to do so, 1f lhe Norn nee predeceases the [4ember {Employee) or
his eslate
.1. The appo ntment of Nom nee or change thereof ,na.Je from time io lirne shall take efiect lo lhe exlent
rl rs vald on the dale on Lvhich it is recerved bv the lruslees

P"'.1yo \"4
I

TO WHOMSOEVER IT MAY CONEERN

DPAh)'+Nl 1\'+J
I,' , employee of l\lax Bupa Health lnsurance Co. Ltd.,
having employee lD do hereby declare, confirm and
state that as on date of this declaration, none of my relative
including spouse, dependent children or dependent step
children, whether residing with me or not are working as an
agent or employee with the company. lt is further declared and
affirmed that as and when any of the relatives applies for and/or
becomes an agent or an employee of the company or
approaches the company for acting as an agent or for seekrng
employment, I shall duly inform the company (reporting
manager and Human Resource team) in writing regarding the
same.

pplytfl,a ttDA J
/>j
Name of the Employee: rgna Iure

Designation of the employee

Date t2) )2)2-\'

Employee Number

Branch/Location:,ry3y
-
 TO WHOMSOEVER IT MAY CONCERN

IPW YN D,+) . employee of Max BuPa Health

lnsurance Co. Ltd., having employee ID-.--, do hereby
of
declare and state that as on date of this declaratio n following
of the
my relatiles are working as employee/ind ivid ual agent
company as per the details given below'

Relatives RelationshiP Current Employed

Sr. No
Name with Relative Designation Since
& Function of
the relative in
Max Bupa

Name of the Employee: PPfrhlntl D4{inn"u't' !"VynOn4

Designation of the employee: J l(4DD Date /2 /tl t; Z.
Employee lD:

Branch/Location: lrw-

l
I
,

( ()\II"\N\ \ \NII.,
C( )\IPOSI l'la l\F() lrl r,r ttt ti'l sttlluL'
(lbr internal Lrst otrl) )

t.( )R ( ()lll',\ l'\ t sl.l oN l-\

I', t. No
No lo lt lille(lby P.F.Trust)
(1' F
EDrplott( {lodt lt
Dalc ol .Joinirg

TO BE FILI-ED IN I] Y',l1l E EIUPLOYED

Plexse lrl1if lhc lolnr rn lour oqi handurilin!

p \ t) A t) I
I)^te 01'Birth }k) olJ q q I

r.attt rl I Llfiarla ( lr C t) I L ia L/ Ea4l f) A

L -rlind a!4
t T .p U t A I F ( lt D
I

A|tf tFs

I'in Codc
Nlolrilc No.
'I clephorc r."o

l'cr. E-l\'Iail lt) n .i (lt l1 )

c 1l> gl7 AL l
I'AN NO, I 6 .T 7l Dl e t, ) D

tlnrplorct

lJntlk A/l. No. z L)

El c c) bl\ t \ f .1

c 0 4 4 N )4-
N A4.lp AID v) 4h -_t
j
PIt o\'l t)1.-i( t l'tiNI) l)ll'l',\ll-s

, \\ ' l ir 'r " ' ' \''i ,',.. a, a..

, ll ) ( LL fL(.. , li. ,re I ll \/r \
: iil;,i.; y.,"ii'rl1,"r"...r'r"''r\'rrhI'r' rru\t /rilr:(l

tw tvg
Signature
 Employe. co'Je
( M. n.l a to rY)
FORM 2 (Revised)
(Fo. Unexempler:l /Erempled Establ shments)
NOMINATION AND DECLARATION FORM
lDeclaralron.ndNonin.liofFolrnLndcrtheEirpoye{rsPro?rderrl'rrfdsandEmpoyeesPensronSchenr-')
1952 and paragraph 18 o{1he Enrplove's Pensioi Sche'ne 1!95)
phs 33 & 61 (1) olthe Emplovees Prov dent Funds schenre,

1 Name (in Block Lctlers) nAAtl'.'A

'LL\ll)L
N "ll-. \At.
2 FathelsiHusband's Nanre )LL"'
3 Dalo of birth \.lcr trL/iq ql
Sex P f-m ?^
'
5 I arilalStalus i+P!/t' ^'
6 Account No. rr'r,r ,i"6", PN/ )13321 rzr \A( , tl^ (
pArmaneli L!.rr \ --\.!i. p r" P \
7
*l'tt
ii,,
remporary Nt '' 't "
PART A (EPF)f;
I tr.reiiy nonrinalc the pc,so.(s)/cancelthc or nralc ov rrei'ev ouslv inrd nonrin'ie lrre petsof(s) trre'non'd
'cmlnar t-'rovr'lcnI F!nd rn ltiL' evenl ol trr! dealh
below 1o rcce ve llrc amo!nl slan.lrnq lo firy cre{:l]t n lirc i:rDlcyees

Name 3nd Add,ess oattre nom neer nominees

Birih

(5)
l2l (31 t4)

L
1

O I/JE tt)aj)*, o" l" 4'

^/

10Oo/o

* ce.trned that I have no familv as defined in para 2(s) orthe Emplovees'Prolident Funds Scheme' 1952'
and
1
nomitration should be deemed as cancerreo'
shoutd I acquire a family hete;tter, the above
2 * certitied that my fathe./ mothe. islare depend€nt upon me'
3. * Strike outwhichever is notaPPlicble.
Dau'
Signature or humb impression of the subscriber
by thc member on his marriage and any nomination m:'l'
b'lore su'h ma iaqe
Nol.a: - A Freslr nomination shall bc nrade
shall be dcemed ro be invalid

Page l,ie. - 1
\tAx I\i)ll l-l\r ll l:l )
 Pdrl B (tPS'j 1P 'r' la1$
wnlii b' el ! 5l' l' r'ceLv' w dowi' nl'lrerr P'ns
I h.reby lurn :ri' b. ovr partr'u irr! ol lire rnc'nbcr: ol nry larn lv s4rn "
.1he evcnl o{mY clcalh

SI.No. t'tame and address ol the tamily membe i, Date of Birth RelationshiP
the member

3 4

1 v) LL) I lLt/ /n AJ t\ lo _1 lpll sE ,

2
3

4
Pcns on schemc 1995 and should lacq! rc a
" Ccd I e.l thal have lro iarnLlv as dalined Ln para ziv i) cl Emplovees
thereon Ln lhc abovc lornl
ra- ry r.",earre, I sral rurnlsh partrcuLars
2(a) ( ) aid 1rr)
w dow pc'sLon cd-::'bL: 'll!:l I ll:j"'J
ale the roLrowrnq persons ior 'eccivirs the n)onl 'r/ lrn lv lrL'nb{rr lor rccevLnq
(r EmllJ,eL P.nsron Schcnre, l9e5 in the cvenr -), o""iii *'rt"ir""r'ns rnv clqLre
"r
P'! $,
Date ol Bitlh Relalionshi with the member
Na a d Ad dr ess of t h e Nom n
(2)
1

v C bA-

sioilature or thumb imPresslor

oJ lhc sub:cr iber

"slrike oul whichever is not aPplicable'

CERTIFIC ATE BY E MPLOYER
be{ore rJre bY
Ccrlriied thal the abole .leclaral!on an'l fonrrnallof lras been srqn edxlrumb impresscd
loyed Ln mY eslablshorenl
Shii/Smt./KLrrnarL
read over !J hrnr,rhcr by nre afd got co
a,tcr he/she has rea.l the cnlres/thc entries have been

1 Dalc oljolnln! EPF 1952

2 Dale olioinin!l FPS, r97l

3. Date ol jo ning EPS. 1995

Place: --
Daled the

-.-
r)esrofitiorr..
Nrme rn-d address ol Llrc Fi'rorvrEsl'blishmcnr
rubl'/cr 31'mn lherc!r
'r

FrqeIq, ?
l\r\x l\l)1.\ .lvll Ll)
 ,ior.i c tcl
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'\'i'., nE !? i, ,r t E@ ;1 rj qni 1? a i{- r: m i i,+ I
6 r rog.chs ro bc atu..od $rh F.

P 2+41ai.] DA t
gr\HL ILU D41

)t ot qt

!I

.iF P iri q{ }hr 36,s

i.rrantufiiftn in + Im; Fr.rn iinF !r<.nn..nr r.nri ii€ E! +ha a, i inrnr#
I *anu c i6rl or Fs) i.din,1 nra5

(,^)+ra- tav. DD.-) / tz)v tL, L4

fl 1!r-h? ir Fn+ ir€n r ft,z: w n t,: *i qi.tn ji:i 1{ 'F-n r rn
,;; i "iF r&r. r7i s r- li,

f.o g.t,1 lYz-i '

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 lHsTlrucrrors
nr4 1r!re)iiirq rliri,In:rrr, r rr{ r;4r r?r;rlr,r rirl jJ ;

l': .! i
'
rr'{ { )t af,ir h) n{!n nirr :rnqi ,r !F - r{ F@ }1l* l:E rr rri 66 ;l a,nl? at-
i :v:iir cr !"in: ,ta? a aa n r{ttu.r ,8,.r ,.i :. iri :, nn fl qn ?, irr.n (E) n] lrfrafrn 1i
nr a. rm i tui i.nE ,ar hrirr :flr,rrn q il: ; r,! i tr lilffi r.i a. :qrn i, r
'niiFh
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,la)y.lneznsa
1)a su5e (i) a m@, rs,rmde d P:rr3d,bqho€s.yd3ocd.dc.li.
eariosoirherP mdiDE(a)16 rsdsranaEseageor2ry€38(b),iLrm nrrd{roh:.r.
(,o : .h rd !i& 6 ii6m by f:in d
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, rip F ;i ,lq ai { leir i ftj@,m rir ii a4ra {tun liFr ?.11
Lo* o dedry cad e Gped b Enprorer,€raid u3E d medrard,
! ,nir !.n d -,e- Efl:i, i{h l6r.n }ifrrc rer! S mrr n ffi qin sinii +j n.nn i,

6 < ffan;i iiiti ii qii liIi r{ (r, {. ,+rt Fq,? a a lir i 'iF iitrar s-ll mifl n fi1q li lrTd i.!r
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t;rm r, ryn trFrr ln+ r'r)rirlr:tr,.rr i.j{rc 1, }f!n-H iirrF 15) r-rir i:ff{ rliF rEn , 1n,) r

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rd ltr rkrf ly 3.r11tr.ise or

+< !m 6'ql@ I cah aE

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kq{aii1*]::i@:rrEirIar n -+a}, i

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=
 NewFormNo.-ll De.larationFo.m

EMPLOYEES PROVIDENT LINL] ORGANIJATION

'
lDt.iaia!onbyapr6o.r!kingupcmptoyd.nrnr.ny.rrabtishm.nrofyhi.hFpFs.hcmetg52.nd/o,Epst99t,appl,(ible)

u l
Y+r! D +t 1

U
.:.id.r (^tL/rem,Le/idtrqriderl
61i, t !!r!! (Min elllrrfu r.d/w now,l!
o
dowlr,/Lj r,.r.)

n+ Lt\ 9 ,Qh,
rov deir runal nbm. rs.,)

previour.mproymeirder.,t,r I ryer ro
c,
7 aND/oR 3 abovel
a) un v.cr^r.ounr Nu nt)!r
s,-tD
b) Prcvrous PF A..ounr Number
.)D.ne.re n.rnpr.vouj.4r0roym.nl(rD/MMr.ryyy)
d) s.heme aenifi.rte No ( rnied)
8)P.D!.n P:ynre.rOrde, r!)No r trn,..I
'

bl,ye5 nar.o!nrryof .r!ri1ri!rNimcororrrer.ounrry)

d)v:,dryorPdnp.nt(rh1N1,/yyyy)r.loD/Mlryyyyr
D.raL Gii:.h n, Ji.i.. (,Drc: otro l.w i_u Xra,
a)errrA..ounrN! &.sa.d., L' o I F\GUCA4 y)t
a Pr n.ripnlrlllrxl N!nr,l rrANl Lr'r; ..rr.

r) a. ited lh ih. !irt.!rr^ iri rru. !o rhe r4( or my kno{t..lqe

) I aiiho,re tPl o ro !!." iiy A.,d
]](tdyU,[l..lhef!ndr:i.ihcprPviLllPFi(o!i1.Jd..|l.
4)r'r.:!eor.rrnqe.nalroy..r.r:i5,h?nrreurrbriiim:t.droenrptof,3rrh..iriri

l"ytpn l-)
s,s*',*.i""-u*
Ur
DECLARATIOtr gf PREsENI E!44OYE!

A. rhe menrb.r Mf /M!/r\4L

:no' h:s b.!i.l ot.d Pr Numb,er

0 rhve be,,lPtoad.dL nd dppo{.d

0 rivebe4i !pb!d{.i rrripprcrcd,njD5.

riqnarure ot Lmploytr vr(h 5e.