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Anrrcxurc - VII
NEW HEALTTI NSURANCE SCHEME. 2012
to. Etnplots d Cort D.9!TEE ra cf#E G.r.r!d E& ttb :rdrDe
l. \a'E o{'the F't*---rE '
C@VotiLt$.
tt I' w qru&rL
('h*&
LFIrbt
h.q-rJ.)
TCi4qF4-,rd.t
Hi6!m.
1 DcsignatlE
3. Pay Drawo Patbularr
4.H€d of Accouar in s,hicb fte Gor4
Erplo;,ee's corributiocr fu being
Pay in PB + Gr.Pry = Total
144+'1
&orf*
DD - \bq AG
5.T.?€ of Offcc
6- O'fficc in wtich Ernployed
7. Dat€ of Birth
8. Date of Appohh€nt
9. Date of Retirenent
10. Design tioD of DDO A Codc
11.Pay Drawiag Ofice att ched
(PAO / TnarEy / Sub-ttE$ury Fith Addlr!
for cort. E!4toye€6 )
Olhfls - Addr6s of6c o6ce
Go\/fmmant
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Anpruc - YII
j,'
NIETY HEALTH INSI,JRANCE SCHEME. 2012
hhLF .acrt D{arffi rdorfader oraa.d ua..tHr Eaiaoc
Form fo. lhrphhhc lhh of Epnlwr' |od |l.|I.lHblc Frnllv Mct[bcr! lor
tnsurence coverrre undcr New Heddr Innrrence Schemc 2012 to lorunma
Co|rBtrv / Tbd putv AdnhLtrdor.
1. Nme of tte F,4loyec t
Corfgct Mobilc No.
Gr. Rnvt
(i I' * e. T(D b 4ot!4 lh! dddL of
6!Tor.d{ &t bi.dhth..m.
ft,E i !.?drdy, )
2. D!8iglrtioo
3 ?.y Drrttr! Prtbulr!
4.Hcad of Arrcouat h c,tich &c covt
Enplry€.'! oontrihtin i! bcitrg
rccol/!(ld.
5.Tpe of Ofrc€
6. Otr c in which E|DployEd
7. Ihte of Birlt
8. Datr of AppoirtEcNrt
9. Drte of RditteD€ot
10. Dccig!.tim d DDO & Codo
I f .Pry Drrwing Ofrc€ dt chd
(PAO / ft!.nryl $rbftary ?b Ad&!..
t r Covt. F.ddoy.s )
. Othro - Addrar oftta ofiloc
12. E&doy€. Cod.r'
('.CPF/CPS4?F No. Pd BEdoyc..)
E!d6y$ Cod. dolr.!'rd|.tr,ltry
Orf,rCdd.
dSd
O F Frc-rj c\gSl th'.fl
Pty in PB + Gr.Pay = Total
t-an
t---:-.:::J
* l-tEcol- lE66l
&o\\- o'D- \oS' bs
Gowrmcnt
$1 S Tq\c\

13. Details o{ thi Employoe and thei!
eh,qible Fandly Me crs unde! thc
\IIIS,2012
SI
\o
rr{ame
Relalionsbip
Age as on
to the
0t.06.20r2
E6ployeo
\,tarira]
Stalus
ElDploy
ment
StalCS
Srarrp size
Photo
Cn, P.nvr +U \"$tr,*J
ot\
h aNl\4r
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I
l
R. S^E\r'rs\
{2 'e$ \\)hr$ 44. LD\e"
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6
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SignatDre of the EroPloyee
Crnifiei that the above particulars are verified {ith the S
ice Regists of the EroPloye€
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N€\^r
1.,
- _Amcrruc - VII
NFW HEALTH INSURANCE SCHEME. 2OI2
hhrlt . dc.n Dtdq! [d Or|rdrt ..rtr.d thd.r tit S.i.dc
Fo.E &r lbilh
tlsunn."rrre
Ddl of Etnbbvr.trrd thGlr elHblc F.m v Membet! for
rrller Ner Eeddr Imrr?rce Sctrene. 2012 re fgur.o"
C6rav / THd p.rtv AdolrLtrrtor.
1. }Ic dtu Eafolcc I
Co@ l4oh]o No.
N. s\Uh\!q\Jqk16n
(. h c- tu
traatbb.filiitd
"-i
hAr.dr.)
Gdq/l4 tb. rt ralt of
htt|,rd.
Z Dcsignrtn
3. Pry DnttmhLJlt
4.;i.d of Aood|d h q,nich tho Govt
Fq{oy€€'s omtibution i! bcillg
|tgol,ttcd
s.Typc of Oftcc
6. tjffcc in wtbh E4loycd
7. D& dBidL
8. D*c of Appohmcat
9. Dat€ of Rdi&acar
f0. DcdigDrti.n d DDO & Codo
f f .P.y DrrwiDg OdEc. d*hrd :
(PAO/TtEary,/ eb-Ttraly Fi6 Ain6..
6r Cotd. EEddy... )
;PryinPts + Gr. Psy = Tobl
lzsEl * fisl= l-sEl
S.ott* -"o - los A I
udaaD4ctrt
Ptrtrc r{ra\ ot^S,,ffu\t,
o8-b5-\qtq.-
oB ^ lb - )a\b
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ttffiEffir'*r*r,r.r.-r' eps 1\\qur68l'ludL
E doy.. C.d. dqlro.ldd;a if ny ted dil t H.ad d.narift rt id.dldr dlh,
ts"d$e
3f) c ".'!-
Itlir..,Vu\rt t r

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13. Details of the Edrployee and their
eligibie F'eurily Membcrs under thc
NHIS,2012
SI
.\o
Neu|e
R elatiohship
Age as on
to the
oL.06.2tt2
Employee
MaIitul
Slatus
ErDDlov I -
."nt- |
btfllj'
stales
\ . S\vS r$fi t0
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Alrprurc _ VII
- -
NEWHEALTH INSURANCESCHEME,2OI2
!- Feplrts oacdt D.?.rt!.ilb Dr, (}trdrdr..-...o J;-|tt s"i.."
. Fonp lor lurdlhlna Drtr ofEpdov.ce .ad th.lr Chbh FrrElh lrctlb€E for
*ur"o"" -t ..o.uoo"r*"*t-* ffiffio""
l. Nme of tic Eq,loyee +
Codtact Mobilc No.
F\ f, EC^A\!hT\+AN
: t l
,tB o&45q\q
(i ltra e. T(t' b ddoyl th. dddl| of
or. T(trD ttdt dro b. fuid hth. @.
fiErdrqddy.)
2. Dcsiglrriotr , [r\Annk, h r
3. Pay Drartr Purbuld! : pry inpB + cr. pay = Totrl
lET6l *.rrE=l-t6l
4.Hsd of Aca.uf in which fte Govr
Enployc€'s catrEDution i! beinq
''(il'.d.
5.T1pe of Ortrc,c
6. O'ffr€ m c/tbh Eqloyrd
7. Da& of Birth
t. Datr of Appoith€trt
9. Dare of R€tiftmcat
r0. Deeignrtln of DDO &, Codc
f l.Pry Dnwiog Ofic€ .ttrtrcd
(PAO /'ftE !ury/ Sr|b-Ifsry*ifrAddE
tq covt E4oy€ )
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; Gqnrnurtlt
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ir\ 5or-
'
b\,thtcr, ?\

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t3. Details of thc Eoployee and their
eligible F'aurily Mombers under lhc
NHrS,20t2
S1
Name
Relationship
Age as on
to the
01.06.20I2
EEployee
Mariml
Status
Eurploy
mcnt
sulles
Slalrp size
Pboto
i l0.tPoroun
Trl6u
4S
sdrt,
\*\d
I
t 2
I
I
It'
S DNbSL 43 LD\te $F,$,\uf
T .'\ trF \h
" ilr-nu'l$Atr) \q N) ut\
\ovr\\.rol
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6
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Anrcrurc - YII
NEW HEALTH INSTJRANCE SCHEME. 2OI2
fc EDpfrtr.. oa cort DrTlttunE .!tl (}t rdrd5 c.r..td rira., ttL S.i.oc
Form for frrnishina Datr ofEmployce rpd ficlr elklHc Frrplly Mcmb€B for
tnsurance coverrge uq_der New tl!:dqt Insrnnce Sch€me. 2012 to lmurence
comoruv / Thlrd orrtv AdmhkiirtoF
1. NaBe of rhe Employee * t p. fl^a-rr.'uQan]
contaot Mobile No. ,t CtS66g"l OOLI
(+ In csc lbr ipdr. h qioy!4 tl! ddiiti of
0r. BIqe dl*t hin dinrh.lrn
frsnd.4q&V. )
2. D€si$aaicn
3. Pay Drafir PdticularE
4.IIed of Ac.ount in which Govt
Employ€a's contr:bution is being DlA _ O0 _ l}F AB
recovqrcd.
5.Type of Ofic€ ,. : Cowmmcnt
6. Cfic4 in wldch Etnployed
7. Date ofBirth : 11.05 1F
E. Dat ofAppointment , 3. lO. ?A
9. Dale of Retirener g I, f oZ? ,
r0. D€siFation of DDo & codr
l l.Pay Drawing Offoo attachcd.
(PAO / Tftnffy / S!b- ItFluly pith Adfr!..
.br CoW. Employ€.s )
- AddEss ofihe ofrce
, Jt- 8sr
:PayhPB + Gr.P{ = Toral
r='T-':--r
l44b I + f4Aod = f\l-a6oi
, Psrnc,iea l' )iStn'r+
: B 40.q
DiJro i c.l- Tre,c.9", q
'lltl!rlr\Va{n
12. Emp.Ioy€€ co&.. ,^ nr : &8 514 1ra' .
f'CPF/CPSVTPF No. FdEnploycd) !r {'
tfi.oett *"4 if nv..(srdd'dlt bu.rd&3rierth.ud!&drh.
ffiff
Judge

i3- Dciail-r ofii. t-fl}Picy.e anC dleir
elictble !rz!urily N4clrbcrs ondet thc
!ii
r-" i
Name
Relalionship
Age as on
to the
01.06.2012
Employec
\'tariral
Siatus
Euploy
menl
stales
S,"-p "irt
l
Pl'9!
n A
. \1m,t ( ,/.\rl,.nuj'4r" 3L rl b,(b\w(
I t /
', \c,- Q Fal^!.whca,z
f)r.,{ ba''{ _ d"-
I
i t .
', I n '( ru? ''nrt lo c,te.tfhW
Q |o.*^na*-
Signature of the EBPloYee
Cernfied that the above particulars are verified witt the Service Regisu of the Employee
Drrs: