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Annexure IV

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62 views

Annexure IV

zsfdgz

Uploaded by

logeshkumar111astro
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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THE GUIDELINES FOR IMPLEMENTATION OF NEW HEALTH INSURANCE SCHEME, 2018 FOR

PENSIONERS (INCLUDING SPOUSE) / FAMILY PENSIONERS.

ANNEXURE-IV
(See Guidelines Para-5,6,12,13,15 & 17)
Photo
FORM FOR FURNISHING PENSIONER /
FAMILY PENSIONER DETAILS (1) Photo in case of
Family Pensioner.
(2) Joint Photograph
[UNDER NEW HEALTH INSURANCE SCHEME, 2018 FOR in case of
PENSIONERS (INCLUDING SPOUSE) / FAMILY PENSIONERS.] Pensioner.

1. (a) PPO No. :


(b)Name of Pension Disbursing Office :

2. PPO No. (in the case of :


Pensioners who are getting payment
outside the State)

3. Name of the Pensioner / Family :


Pensioner * (in BLOCK LETTER)
4. Name of the Spouse in case :
of Pensioner (with Joint
Photograph).
5. Bank & Branch with Account No. :
from where the Pension / Family
Pension is drawn.

6. (a) Permanent Address :


(in BLOCK LETTERS) (Duly
furnish District & PIN Code)

(b) Present Address :

7. Contact Details :
(a) Phone No. with STD Code :
(b) Mobile No. :
(c) E-mail ID (if available) :
8. PAN No. (if available) :
9. Post held by the Pensioner at the time :
of Retirement.
10. Office / Department from which the :
Pensioner retired.

11. Pension Drawn Particulars (whichever Original Pension : Rs.


is applicable) Commuted Amount : Rs.

Provisional Pension : Rs.

Family Pension : Rs.

12. Date of Birth (with proof)


(a) Pensioner / Family Pensioner :
(b) Spouse (in case of Pensioner only) :
13. Date of Retirement of Pensioner :

14. Details of Legal Heir


(a) Name :
(b) Relationship :
(c) Phone / Mobile No. :
(d) E_Mail ID (for :
communication purpose).

Certified that the above particulars furnished by me are correct.

Signature/Thumb Impression
of the Pensioner / Family Pensioner.

Certified that the above particulars are verified with the


PPO/Pensioners ID Card and found correct. The subscription is also
being recovered and remitted into the relevant head of accounts.

Signature of the Asst. Adm. Officer/Adm.Officer

Name :

Designation :

Date :

Seal :

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