Mediclaim Report_All family details

JHARKHAND STATE LIVELIHOOD PROMOTION SOCIETY

 

Mediclaim Format (Only For FTE Staffs)

 

Name of the Employee:	Phone No: (1)	(2)
Employee Code:	Date Of Joining
District:	Block:

 

Member Name       (As per Aadhar Card)	Relationship	DOB  (As per Aadhar Card)(DD-MMM-YYYY)	Sex
	Self
	Mother
	Father
	Spouse
	Child 1
	Child 2

Note: In case of Female Staff, they can add either own parents or their in-laws.

 

Declaration:

 

I ______________________________do hereby declare that the information given above is true  to the best of my knowledge and if any information is not found true I will be liable for any disciplinary action.

 

 

Date:-                                                                                      Signature of the employee

 

 

Palce:-                                                                                     Signature of Unit Head

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