VMRF-DU GMC - Puducherry

Basic Details

College^*

Employee Code^*

Employee Name^*

Email ID^*

Mobile No^*

Gender^*

Date of Birth^*

Age^*

Department^*

Designation^*

Do you wish to include your family under this group medical insurance ^*

Sum Assured^*

Family Member Details

Name^*

Gender^*

Relationship^*

Date of Birth^*

Age^*

Action

I hereby confirm that all information provided in this registration is accurate and complete.

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