ANNEXURE - VII
New Health Insurance Scheme - 2016
(For Employees of Govt. Departments and others)
FORM FOR FURNISHING DATA OF EMPLOYEES AND THEIR ELIGIBLE FAMILY MEMBERS FOR INSURANCE COVERAGE UNDER NEW HEALTH INSURANCE SCHEME, 2016 TO INSURANCE COMPANY/THIRD PARTY ADMINISTRATOR


1Name Of the Employee :
Name of PAO/Treasury Office :
Gender :
Ref. No. (Previous Card No.) :
Mobile No. :
Email ID :
   
2Designation :
3Type of Office :
4Office in which employed :
5Date of Birth :
6Date of Appointment :
7Date of Retirement :
8GPF/CPS No. :
9Employee code :
10Upload Images
Front Scan Image :        
Back Scan Image :