McKinsey & Company, Inc.

- India Office
Medical Health Benefits Plan
Membership Enrollment Form

This is a : New Form Change Form

Name :
first middle last
Employee No. : Date of Joining :
(DD/MM/YY)
(M/F)
Date of Birth : Sex :
(DD/MM/YY)

(M/S/O)
Marital Status : Date of Marriage
(DD/MM/YY)
Residential Address:

City : Pin Code :

Phone : Fax :

Details of Dependents :

First Name Middle Name Last Name Date of Birth Relationship

Instructions : 1. Please fill all Information in CAPITAL Letters.

2. No Medical Claims will be processed without this Form.
3. Please attach 2 recent ID Card Size (4” x 3.5“) photographs of
self and dependents.

Signature of employee Date : _____________

UnitedHealthcare India (Private) Limited

3B Gundecha Onclave, Kherani Road
Saki Naka Andheri (East) Mumbai – 400 072
 Telephone : + (91 22) 306 57300 Facsimile : + (91 22) 2852 - 8222
1st Floor, 5, Community Centre, East Of Kailash, New Delhi - 110 065
Telephone : 413-24266 / 413-24267 Telefax : +(91 11) 413-24296