VMRF-DU

Employee Details

College^*

Employee Code^*

Employee Name^*

Date of Birth^*

Age^*

Gender^*

Department^*

Designation^*

Phone Number^*

Emergency Contact Number^*

Email ID (Personal/Official)^*

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

Sum Assured ^*

Name^*

Gender^*

Relationship^*

Date of Birth^*

Age^*

Action

Declaration

I hereby confirm that the information provided above is accurate and complete to the best of my knowledge. I have read, understood, and agree to abide by the terms and conditions outlined above.

VINAYAKA MISSION’S RESEARCH FOUNDATION

Insurance Enrollment Application Form Employee Details

Employee Details

Declaration