Careers For Life @ Max Life Insurance

Check List
Have you completed your documentation …
Appendix Forms

• Submission Of Documents
9 Curriculum Vitae (CV)
9 Application Sheet of Max Life Insurance
9 Copy of Accepted Resignation / Copy of Resignation Letter Submitted
9 Copy of previous Salary Slips / Most recent Salary Revision document
9 Experience Certificate
9 Copy of Educational Certificates
9 Copy of Acceptance Offer
• Completion Of Forms
9 Terms & Conditions of Employment
9 Statement of Compliance with Business Code Of Conduct
9 Group Medical Insurance Scheme
9 Nomination for Group Term Life Cover
9 Form 11 (Revised) - Employees' Provident Funds Scheme, 1952
9 Form 2 (Revised) – Nomination & Declaration Form (Fill in DUPLICATE)
9 Form 19 - Employees' Provident Funds Scheme, 1952
9 Form 10-C – Employees' Pension Scheme, 1995
9 EPF – Form for Allotment of Social Security Number (SSN)
9 Payment of Gratuity (Central) Rules, 1972
• Getting Started Forms
9 Employee ID
Will be generated within three days of your submitting the joining report
9 E-mail ID generation
9 Opening of Bank account
Collect Form from HR/Zonal HR/Office Coordinator (in case separate form
not in handbook)
Within 10 working days after submission of form you should receive your bank
account number along with Debit Card from the bank
9 Tax Consulting
9 It is important for you to speak to the tax consultant within a month of your joining
9 Visiting Cards Request
9 How to claim MOS bills
• BRE Declaration

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 Career For Life @ Max Life Insurance

List of Forms
Appendix - Forms

Appendix Forms
• Terms & Conditions of Employment
• Nomination for Group Term Life Cover 9
• Form 11 (Revised) - Employees' Provident Funds Scheme, 1952 11
• Form 2 (Revised) Nomination & Declaration Form 12
• Form 19 - Employees' Provident Funds Scheme, 1952 17
• Form 10-C Employees' Pension Scheme, 1995 19
• EPF Form for Allotment of Social Security Number (SSN) 23
• Payment of Gratuity (Central) Rules, 1972 26
• Medical Insurance Coverage Form 30

29 Max Life Insurance / Human Resources New Employee Code 2

 Careers For Life @ Max Life Insurance

Terms & Conditions Medical Insurance Coverage Form

1. Confidentiality
1.1.The Employee will at all times observe the strictest confidentiality regarding all Employee Name
Appendix Forms

Confidential Information pertaining to Max Life Insurance Company Limited Employee Code
(“MLI” or the “Company”), its affiliates, third party contractors, vendors, Location
consultants or service providers. For this Agreement Confidential Information
shall mean, all information or data (in any form or medium) disclosed to the
Employee by the Company or by a third party acting on behalf of the Company Details of Self & Family (For Coverage under Medical Insurance Scheme)
and shall include without limitation Particulars Name DOB/ Age Gender
(a) any information ascertainable by inspection or analysis of samples; (b) any Employee Name
information having been disclosed prior to the date hereof; and (c) any Spouse Name
information relating to the Company's business operations, underwriting
standards, actuarial data, processes, business plans, intentions, product Child 1 - Name
information, product documentation, product plans, investments, know-how, Child 2 - Name
rights, trade secrets, customer lists, market opportunities, business affairs,
computer programs, hardware configurations, engineering specifications, and
other business practices. Additional coverage allowed on payment basis only
(One time premium deduction is done directly from the salary on pro-rata basis)
1.2.The Employee agrees and covenants with the Company:
Particulars Name DOB/ Age Gender
1.2.1. To use the Confidential Information, solely for the purpose of executing
duties in the course of employment and for no other purpose and in particular, Father's Name
but without prejudice to the generality of the foregoing, (i) not to make any Mother's Name
commercial use thereof (ii) not to use the same for the benefit of himself/herself
or of any third party; and for any purpose whatsoever, without the prior written
consent of the Company; Important:
1. Insurance coverage is not extended beyond two children, not even on payment basis.
1.2.2. Not to disclose any Confidential Information to any third party. Disclosures
2. Insurance does not cover brother, sister (above 18 years) and In-laws.
of Confidential Information shall be strictly on a need to know basis and in
accordance with the policies of the Company; 3. Insurance renewal date is on 1st of December every year
4. For any clarification on coverage please contact
1.2.3. Not to copy, reproduce, reverse engineer, disassemble, modify and/or
replicate in any manner, the Confidential Information or any part thereof, Medical Insurance email ID : [email protected]
without the prior written consent of MLI; 5. You can take print-out of your ecard from Max Bupa Protal - http://healthlink.maxbupa.com

1.2.4. To return all Confidential Information and materials based thereon (and
all copies thereof) containing Confidential Information immediately on cessation
of employment for any reason whatsoever.

2. Ownership Of Intellectual Property Rights

MLI shall retain all ownership in and to any Confidential Information that is disclosed
by it hereunder including all improvements, modifications or derivative works of its
Confidential Information and/or any patents, copyright or other intellectual property
rights therein. Employee agrees and undertakes that he/she will not have any
proprietary rights in any Confidential Information or other Intellectual Property Rights
disclosed to the Employee during the term of this Employment. Further, the
proprietary rights in any derivative works developed by the employee based on any
Confidential Information or Intellectual Property Rights shall vest with MLI, as an
employer.

3 Max Life Insurance / Human Resources New Employee Code 28

 Career For Life @ Max Life Insurance

Certificate By The Employer Terms & Conditions

Certified that the particulars of the above nomination, have been verified and recorded in this
establishment. 3. General Covenants

Appendix Forms
The Employee shall not engage, directly or indirectly, in any other gainful or commercial
Employer's reference no., if any Signature of the employer / officer
authorised Designation employment, activity or business for profit during the Employment. The Employee shall
honestly and faithfully conduct himself/herself and duly and diligently perform all the duties
............................................................. .............................................................
devolving upon him/her in the course of employment of the Company. The Employee will
devote the whole of working time in the work of the Company and use his/her best
Name and address of the establishment /
rubber stamp therof endeavors to promote the interests and welfare of the Company.

4. The Employee will truly and faithfully account for and deliver to the Company all moneys,
securities and other property belonging to the Company which he/she may from time to
time receive for, from or on account of the Company and that upon cessation of the
Date..................................................... employment, he/she will at once deliver to the Company all notes, data, tapes, reference
items, books, documents, effects, money, securities or other property belonging to
the Company or for which the Company is liable to others.
Acknowledgment By The Employee
5. The Employee shall be bound by all the rules, regulations and policies, including without
limitation the Business Conduct Standards of the Company, now in force and by all such
Received the duplicate copy of nomination in Form F filed by me and duly certified by the
other rules and regulations as may be hereafter passed and called to his/her notice and that
employer.
the Employee will faithfully observe and abide by the same.

6. The Employee shall not use any of the Company's facilities or Confidential Information to
enter into speculative trading of any kind either on his/her account or that of another person
or entity. The Employee will not enter into any transaction with other competitors of the
Company (life insurance companies), which may adversely affect the business interests of
Date ........................................ Signature of the employee the Company.

7. THAT, during his/ her employment with the Employer, the Employee shall hold himself/
herself in reasonable readiness to move to any of the offices/divisions/departments whether
existing or to be set up, in the same town where the Employee is currently employed or
anywhere else in India or overseas at the sole discretion of the employer on the terms and
conditions of employment applicable in the place of posting. This move may be within the
employer or to another firm/company which is an associate or sister company or wherein
the employer has business interest either financial or managerial, provided that the total
emoluments drawn and benefits applicable at the time of such move are not adversely
affected in any manner.

8. FURTHERMORE, should the Employee decide to resign from the services of the Company,
he/she shall notify the concerned functional head in writing at least 30 days in advance.
However in case of a probationer the notice period shall be 15 days. Failure to give such
notice or quitting before the expiry of such notice shall result in forfeiture of the
proportionate total employee cost (“TEC”) then in effect, in lieu of such notice being given to
the Company. However, the Company may at its discretion relieve the said employee
before expiry of the requested notice period and in such an event, no salary in lieu of notice
is payable or recoverable to/from the employee.

27 Max Life Insurance / Human Resources New Employee Code 4

 Career For Life @ Max Life Insurance

Statement
Terms & Conditions 1. Name of employee in full ............................................................................................
Appendix Forms

9. The Employee shall not bind the Company against a third party, in any manner whatsoever,
2. Sex ..........................................................................................................................
thereby creating pecuniary or other obligations, without prior authorization in writing. The
Employee will exercise his/her best efforts to conserve the resources of the Company and 3. Religion ....................................................................................................................
incur expenses judiciously and certainly within the authorized limits.
4. Whether unmarried / married / widow / widower ............................................................
10. The Employee further agrees that his/her employment shall be subject to the following
conditions : 5. Department / branch / section where employed .............................................................
10.1. No person whose employment is contemplated to be regular shall be taken into the 6. Post held with ticket or, serial no., if any ..........................................................................
organization of the Company as a regular employee until the probationary period as
7. Date of appointment ..................................................................................................
hereinafter described, shall have elapsed.
10.2. Any such employee may be discharged by the Company at any time during such 8. Permanent address ....................................................................................................
probationary period by the giving of 15 days' notice or on payment of 15 days' TEC in
effect at the time of separation in lieu of notice. Village.......................................... Thana.......................................... Sub-division..................................
10.3. If a person has completed the period of probation but has not been dismissed and
cannot in the view of the Company be confirmed as at the end of probation he/she Post Office.................................... District......................................... State.............................................
shall continue to be on probation till such time as his/her services are confirmed in
writing and on confirmation, he/she shall be deemed to have attained a regular Place...........................................
status of employment but the beginning thereof shall be the date of his/her Date............................................
employment.
Signature / thumb impression of the employee
10.4. In the event of resignation/discharge from employment at any time within the first
three years of employment with the Company, the Employee shall not take Declaration by Witness
employment with any other entity/company/organization having similar business Nomination signed / thumb-impressed before me.
interests for a period of six months from the date of relieving/discharge. In the above
eventuality, the Employee recognizes his/her responsibility to disclose this provision to Name in full and full addresses of witnesses. Signature of witnesses

the prospective employer and acknowledging this to be a reasonable restriction

1. 1.
agrees and understands that the Company will have the right to inform the other
entity/company/organization of this provision. 2. 2.
10.5. In the event of resignation/discharge from employment, the Company reserves the
right to process/settle Provident Fund withdrawal accumulations of the employee and
credit the same to the employees bank account in case the employee does not initiate
transfer or withdrawal process within 60 days from his last working day.
11. The Company will give to any person who has attained a regular status of employment one
month's notice for discharge or the Company may pay to such an employee, one month's
TEC then in effect or a proportionate amount in lieu of notice. The Company, however,
reserves the right to have the discharge take effect immediately if such discharge is brought
about by dishonesty, disloyalty, insubordination, moral turpitude or other good cause,
including breach of any of the above conditions, without prejudice to any other rights and
remedies of the Company. Nothing hereinabove contained will have effect or will operate
to the prejudice and detriment of or in derogation of any rights or privileges conferred on the
Employee by any applicable award for the time being in force or any other law or contract
with the Company.

5 Max Life Insurance / Human Resources New Employee Code 26

 Career For Life @ Max Life Insurance

Payment of Gratuity (Central) Rules, 1972 Terms & Conditions / / / /

Form F: Nomination
12. In the event of the employee committing breach of any terms and conditions contained

Appendix Forms
[Sub-rule (1) of rule 6]
herein, the employer reserves the right to take suitable action / and pursue such remedy as it
To deems fit.
(Give name or description of the establishment with full address)
1. I, Shri/ Shrimati/ Kumari ...............................................(name in full) whose particulars
are given in the statement below, hereby nominate the person(s) mentioned below to receive
the gratuity payable after my death as also the gratuity standing to my credit in the event of Signed and delivered by the Employee
my death before that amount has become payable, or having become payable has not been
paid and direct that the said amount of gratuity shall be paid in proportion indicated against
the name(s) of the nominee(s). .........................................................................................
2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within the (Signature)
meaning of clause (h) of section 2 of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the said
Act. Name : ......................................................................
4. (A) My father/ mother/ parents is/ are not dependent on me.
(B) My husband's father/ mother/ parents is/ are not dependent on my husband.
Place : ......................................................................
5. I have excluded my husband from my family by a notice dated the __________ to the
controlling authority in terms of the proviso to clause (h) of section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.
Date : ......................................................................
NOMINEE(S)

Name in full with full Relationship with Proportion by which the

Age of nominee
address of nominee(s) the employee gratuity will be share
In the presence of :
(1) (2) (3) (4)

1.

2. ............................................................................ (Witness)

3. (Signature) Affix passport

size photograph

4.

Name : .......................................................................

Address : .......................................................................

25 Max Life Insurance / Human Resources New Employee Code 6

 Career For Life @ Max Life Insurance

Statement Of Compliance With (For The Use Of Commissioner's Office)

Business Conduct Standards

Max Life Insurance Limited
Appendix Forms

( Under Rs. ......................................................................................................................

P.I. No. .................................................................... M.O. / Cheque ................................

I have been briefed and I've reviewed the Company's Business Conduct Standards. I certify that I
agree with the principles contained in Business Conduct Standards, and will adhere to all Passed for payment for Rs. .................................................................................................
standards contained within.

M.O. Commission (if any) ............................ net amount to be paid by M.O. .........................
...................................................................................
Signature .............................................................. towards withdrawal benefit.

................................................................................. D.H. ...................................... S.S. .......................................... A.A.O ..............................

Name

(For Use In Cash Section)

..................................................................................
Department
Paid by inclusion in cheque No. ......................................... Date .................................. vide

..................................................................................
Date cash Book (Bank) Account No. 10 Debit item No. .................................................................

.................................................................................. ..............................................................S.S.................................................... AC(CASH)

Manager
For issue of S.C.; IDS is enclosed with Form 2 (Revised).

D.H. ........................ S.S....................................A.A.O.................................... APFC(A/cs)

(For Use In Pension Section)

Scheme Certificate bearing the Control No. ..........................................................issued on

..................................................And entered in the Scheme Certificate Control Register:

D.A. S.S. A.A.O. APFC(PENSION)

7 Max Life Insurance / Human Resources New Employee Code 24

 Advance Stamped Receipt
(To be furnished only in case of 11 (b) above)

Received a sum of Rs.* ....................................... ( Rupees ..................................................

..................................only) from Regional Provident Fund Commissioner/Officer-in-charge of
Sub-Regional Office, ............................................ by deposit in my Savings Bank A/c towards
the settlement of my Pension Fund Account.
*(The space should be left blank which shall be filled by Regional Provident Fund
Commissioner/Officer-in-charge)

Signature or left hand thumb impression of the member on the stamp

Re.1
Revenue
stamp

Attestation Of Employer
Certified that the particulars of the member Shri/Smt./Kum. ...................................................
A/c No. .......................... are correct and the member has signed/thumb impressed before me
The details of wages and period of non-contributory service of the member are as under:-
( Form 3-A/7 (EPS) enclosed for the period for which it was not sent to Employees' Provident Fund
Office.)
Wages (Basic + D.A.) as on 15.11.95 ( if applicable) :
Wages as on the date of exit :

Period of non-contributory service

Year/Month No.of days
Signature of Employer/
Authorised Offical
with seal
Date :

23 8
 11. Mode Of Remittance [put A Tick In The Box Against The One Opted]

a) By postal money order at my cost to the

address given against item No. 7
Nomination For Group Term Life Cover
b) Account payee cheque sent direct for credit to
my SB A/c (Scheduled Bank) under intimation to me)

Employee Name : ................................................................................. S.B. Account No. : ...........................................................................

Location : ................................................................................. Name of the Bank : ...........................................................................

(In Capital letters)

Designation : ................................................................................
Branch : ..........................................................................
(In Block letters)
Date of Joining : ................................................................................

Full address of the Branch : ..........................................................................

(In capital letters)
..........................................................................
Proportion by which the
Name Relation Date of Birth
sum Insured will shared
..........................................................................

12. Are you availing Pension under EPS, 1995 ? if so,

Indicate PPO No. ............................. By whom issued ? ...............................................

Certified That The Particulars Are True To The Best Of My Knowledge

Dated .......................………….
Place : ................................... Signature or left Hand
Thumb impression of the
member/Claimant(s)
Date : .............................. ....................................................................

Signature / thumb impression of the employee

9 22
 FORM 10-C (EPS)

Employees' Pension Scheme, 1995

Form to be used by a member of the
Employees' Pension Scheme, 1995 for Claiming
Nomination For Group Term Life Cover
Withdrawal Benefit / Scheme Certificate

1. a) Name of the member :

( in block letters )
b) Name of the claimant(s) :
DD MM Y Y Y Y
2. Date of Birth :
3. a) Father's Name :
b) Husband's Name :
(if applicable)
4. Name & Address of the Establishment :
in which, the member was last employed

5. Code No. & Account No. Region/SRO Code Estt. Code A/c No.

6. Reason for leaving service :

& Date of leaving

7. Full Postal Address : ....................................................................

(In Block letters) ....................................................................
....................................................................
Pin: ..............................................................

8. Are you willing to accept Scheme (a) (b)

Certificate in lieu of withdrawal benefits Yes No

9. Particulars of Family (Spouse & Children & Nominee)

Name Date of Relationship Name of the Guardian
Birth with member for minor
a) Family members
b) Nominee

..................................................................................................................................

10. In case of death of member after attaining the :

age of 58 years without filing the claim

a) Date of death of the member

b) Name of claimant (s)/ and relationship :

with the member

21 10
 FORM 11 (Revised) Employee Code................. (Advance Stamped Receipt furnished below)
Mandatory Certified That The Particulars Are True To The Best Of My Knowledge
Date of joining the Establishment : .......................................................
THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952 (Paragraph 34) Date of Birth : .......................................................
AND Information to be furnished by the Employer if the Claim Form is Attested by the Employer.
Certified that the above contributions have been included in the regular monthly remittances.
THE EMPLOYEES' PENSION SCHEME, 1995 (Paragraph 24) The applicant has signed/thumb impressed before me.
Declaration by a person taking up employment in an establishment in which the Employees'
Signature or Left hand thumb
Provident Funds & Employees' Pension Scheme enforce
Impression of the member
Signature of the employer or authorised official
I .................................................................... son/wife/daughter of Sh.................................................…….
(Name of Employee) Date : ...............................................................
do hereby solemnly declare that : Designation & Seal : ............................................
(a) I was last employed in M/s ...........................................................................................................................
In case, however, the members are physically handicapped and cannot affix left thumb
(Name and Full Address of the immediate previous employer) impression, the thumb and finger impression of the right hand failing which toe impression may
be obtained.
and left service on ........................................................................................... Prior to that I was employed in Note : In the case of submission of application for settlement under clause (e) of sub-paragraph
(Date of leaving with immediate previous employer)
(I) and in clause (2) of paragraph 69 of the EPF Scheme, 1952, the Claim should be submitted
............................................................................................from..................... to .................................... after two months from the date of leaving service provided the member continues to remain un-
(Name and Full Address of the second last employer, if any) employed in an estt. to which the Act applies.
(Date of joining & leaving with second last employer, if any) Advance Stamped Receipt
(b) I was member of......................................................................................................................................... (To be furnished only in case of 8(b) above)
(Name of PF Trust / Address of PF Office of immediate previous employer) Received a sum of *Rs ................................ Rupees .....................................................only)
Provident Fund and also/but not* of the Pension Fund from............................. to .................................... from Regional Provident Fund Commissioner/ Officer-in-charge of Sub-Regional Office/Sub-
(Date of joining & leaving with immediate previous employer). Accounts Office...........................................................By deposit in my saving Bank account
and my account number (s) was/were ...............................................................................................
towards the settlement of my Provident Fund Account.
(PF No. with Establishment Code of immediate previous employer)
(c) I have/ have not* withdrawn the amount of my Provident Fund /pension Fund.
The space should be left blank which shall be filled in by
(d) I have/have not*drawn any superannuation benefits in respect of my past service from any employer. Regional Provident Fund Commissioner/Officer in-charge
(e) I have/have never*been a member of any Provident Fund and/or Pension Fund. of S.R.O./S.A.O.
(f) I am drawing / Not drawing* Pension under EPS 95.
(g) I am a holder/not holder* of scheme Certificate. Signature or Left hand thumb impression of the member
((h) Scheme certificate surrendered/not surrendered*.
For the use of Commissioner's Office
*Strike out whichever is not applicable. A/c. Settled in Part/Full Entered in F.21-A/24/2/9 (Revised) & Withdrawal register
.........................................Clerk........................................S.S.........................................
______________________
(Under Rupees.......................................) Account No..................................
Date : .......................... Signature of left hand
impression of the employee P.I.No...................................................................
Nature of benefit..................................
________________________________________________________________________________________________ Section................................................ MO/Cheque........................................
Shri/Smt.________________________________is appointed as ____________________________________________ Passed for Payment for Rs.......................................
(Name of Employee) (Designation with Co.) (in words) (Rupees.................................................)
MAX INDIA LIMITED
in M/s______________________________________with effect from ________________________________ Money order Commissioner (if any) A.A.O./A.P.F.C.
(Name of the Present employer) (Date of appointment Net Amount to be paid by MO Rs............................................ Date ....................................
[For use in Cash Section]
P.F. Account Number PN/11332
___________________________________
(PF No. with Estt. Code of Present Employer) Paid by inclusion in Cheque No. ...................................... Dated .........................................
vide Cash Book (Bank) Account No. 3 Debit Item No. ...........................................................
___________________
Date : ______________________ _____________________________________ ............................S.S..........................AAO/APFC...........................RPFC........................
(Date of joining of employee) Signature of the Employer/Manager or Other
authorised Officer with Office Seal Remarks

Form 11 Acknowledgment received on ................................................

Verified on ...........................................

11 20
 Employees' Provident Funds Scheme,1952
FORM 19
Form To Be Used By A Major Member Of The Employees' provident Funds Scheme,
1952 For Claiming The Employees' provident Fund Dues (Para 72(5)

1 Name of the Member (in block letters) :

2 Father's Name (or Husband's Name :
in the case of married woman)
3. Name and address of the Factory/ :
establishment in which the member
was last employed
4 Account No. :
5. Date of leaving service :
6 Reasons for leaving service :
7 Full Postal address(in Block letters) : Shri/Smt/Kumari .........................................
S/o d/o w/o ..............................................................................................................
........................................................................ Pin ..................................................
8 Mode Of Remittance :
Put a tick in the box against the one opted : [ ]
(a) by postal money order at my cost To the address given against item No. 7
(payable upto Rs. 2,000/- only) [ ]
(b) by account payee cheque sent [ ] S.B. Account No. ...............................................
for credit to my account in the Name of the Bank ..............................................
Scheduled Bank/or any post office Branch:............................................................
or any Co-operative Branch: Bank ................................................................
including Urban Co-operative Bank. Full address of the Branch: ..................................
........................................................................
........................................................................

Contribution for the current financial year

Period of Period of
Month Contribution Month Contribution
Break Break
Month Wages EE Employer Total Month Wages EE Employer Total
EPF EPF PS EPF PS EPF EPF PS EPF PS

19 12
 Employee Code __________
(Mandatory)

Para 2(g) : Family Means :-

FORM 2 (Revised)
(i) in the case of a male member, his wife, his children, whether married or unmarried, his
(For Unexempted /Exempted Establishments)
dependent parents and his deceased son's widow and children;
NOMINATION AND DECLARATION FORM
Provided that if a member proves that his wife has ceased, under the personal law governing him
(Declaration and Nomination Form under the Employees' Provident Funds or the customary law of the community to which the spouses belong, to be entitled to
and Employees' Pension Scheme) maintenance she shall no longer be deemed to be a part of the member's family for the purpose
(Paragraphs 33 & 61 (1) of the Employees' Provident Funds Scheme, 1952 and of this scheme, unless the member subsequently intimates by express notice in writing to the
paragraph 18 of the Employees' Pension Scheme, 1995) commissioner that she shall continue to be so regarded; and

1. Name (in Block letters) : (ii) In the case of a female member, her husband, her children, whether married or unmarried,
2. Father's/Husband's Name : her dependent parents, her husband's, dependent parents, her deceased sons's widow and
3. Date of Birth : children;
4. Sex :
Provided that if a member by notice in writing to the commissioner expresses her desire to exclude
5. Marital Status : her husband from the family, the husband and his dependent parents shall no longer be deemed
6. Account No. (PF/EPS Number) : PN / 11332/ to be a part of the member's family for the purpose of this scheme, unless the member
subsequently cancels in writing any such notice.
7. Address (Residential) : Permanent
Temporary Explanation : In either of the above two cases, if the child of a member [or as the case may
be, the child of a deceased son of the member ] has been adopted by another person and if,
PART A (EPF) # under the personal law of the adopter, adoption is legally recognised, such a child shall be
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate, considered as excluded from the family of the member.
the person(s) mentioned below to receive the amount standing to my credit in the Employees'
Provident Fund, in the event of my death:

Total amount
Employees Pension Scheme, 1995
Name and Nominee’s Date of If the nominee is a
Address of relationship Birth or share of minor, name & (EPS)
the nominee/ with the accumulations relationship &
nominees member in Provident address of the
Fund to be guardian who may Para 18 : Particulars to be supplied by the Employees already employed at the time of
paid to each receive the amount commencement of the Employees Pension Scheme.
nominee (%) during the minority of
nominee Every person who is entitled to become a member of the Employees Pension Fund shall be asked
(1) (2) (3) (4) (5) forthwith by his employer to furnish and that person shall, on such demand, furnish to him for
communication to the Commissioner particulars concerning himself and his family in the form
prescribed by the Central Provident Fund Commissioner.
100%
Para 2(vii) :- Family means :-
• Wife in the case of male member of the Employees' Pension Fund;
1. * Certified that I have no family as defined in para 2(g) of the Employees' Provident Funds • Husband in the case of a female member of the Employees' Pension fund;and
Scheme, 1952, and should I acquire a family hereafter, the above nomination should be • Sons and daughters of a member of the Employees Pension fund;
deemed as cancelled.
2. * Certified that my father/mother is/are dependent upon me. Explanation The expression “Sons” and “daughters” shall include children [ Legally adopted by
3. * Strike out whichever is not applicable. the member]

Signature or thumb impression of the subscriber NOTE : Members can nominate a person to receive benefits under the Employees' Pension
Note: A Fresh nomination shall be made by the member on his marriage and any Scheme 1995 where a member is unmarried or does not have any family. Such nominee shall
nomination made before such marriage shall be deemed to be invalid be paid pension equal to widow pension in case of death of member.
# If Married –> Spouse, Children (married or unmarried), his/her dependent parents, deceased son's widow and children.
If unmarried then Parents, Brother, Sister or any other person(s).

13 Page No.-1 18
 Guidance For Filling Part B (EPS) (Para 18) $
I hereby furnish below particulars of the members of my family who would be eligible to receive
The Form No. 2 widow/children pension in the event of my death.
S.No. Name and address Date Relationship with the
of the family members of Birth member
Employee's Provident Fund Scheme, 1952 (1) (2) (3) 4
(EPF)
1

2
Para 33: Declaration by persons already employed at the time of institution of the
fund :- 3

Every person who is required or entitled to become a member of the Fund shall be asked forthwith 4
by his employer to furnish and shall, on such demand, furnish to him, for communication to the
** Certified that I have no family, as defined in para 2(vii) of Employees' Pension Scheme, 1995
Commissioner, particulars concerning himself and his nominee required for the declaration form
and should I acquire a family hereafter I shall furnish particulars thereon in the above form.
in Form 2. Such employer shall enter the particulars in the declaration form and obtain the
I hereby nominate the following persons for receiving the monthly widow pension (admissible
signature or thumb impression of the person concerned.
under para 16 2(a) (i) and (ii) of Employees' Pension Scheme, 1995 in the event of my death
without leaving any eligible family member for receiving Pension. $$
Para 61: Nomination
• Each member shall make in his declaration in Form 2, a nomination conferring the right to Name and Address Date Relationship with the
receive the amount that may stand to his credit in the Fund in the event of his death before the of the Nominee of Birth member
amount standing to his credit has become payable, or where the amount has become (1) (2) (3)
payable before payment has been made.
• A member may in this nomination distribute the amount that may stand to his credit in the
Fund amongst his nominees at his own discretion.
• If a member has a family at the time of making a nomination, the nomination shall be in
favour of one or more persons belonging to his family. Any nomination made by such
member in favour of a person not belonging to his family shall be invalid. Dated the :______________
...……………………………………
• Provided that a fresh nomination shall be made by the member on his marriage and any
nomination made before such marriage shall be deemed to be invalid. Signature or thumb impression
of the subscriber
• If at the time of making a nomination the member has no family, the nomination may be in
favour of any person or persons but if the member subsequently acquires a family, such **Strike out whichever is not applicable.
nomination shall forthwith be deemed to be invalid and the member shall make a fresh
nomination in favour of one or more persons belonging to his family. CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by
• 4A Where the nomination is wholly or partly in favour of a minor, the member may, for the
Shri/Smt./Kumari__________________________________employed in my establishment after he/she has
purposes of this scheme appoint a major person of his family, as defined in clause (g) of read the entries/the entries have been read over to him/her by me and got confirmed by him/her.
paragraph 2, to be the guardian of the minor nominee in the event of the member
Place: ________________
predeceasing the nominee and the guardian so appointed.
Dated the ____________
• Provided that where there is no major person in the family, the member may, at his discretion,
appoint any other person to be a guardian of the minor nominee. ………………………………………………………….
Signature of the Employer or other authorised
• A nomination made under sub-paragraph(1) may at any time be modified by a member
after giving a written notice of his intention of doing so in form 2. If the nominee Officer of the establishment
predeceases the member, the interest of the nominee shall revert to the member who may Designation……………………………………….
make a fresh nomination in respect of such interest. Name and address of the Factory/Establishment
• A nomination or its modification shall take effect to the extent that it is valid on the date on or rubber stamp thereof
which it is received by the commissioner. $- Applicable if Married -> To Spouse and Children (include children adopted legally before death in service.

$$- Applicable to both Married and unmarried – (1) Married ----- To any person(s) other than spouse and children.
(2) Unmarried ----- To Parents, Brother, Sister or any other person(s).

17 Page No. - 2 14
 Employee Code __________
(Mandatory)

FORM 2 (Revised) Part B (EPS) (Para 18) $

I hereby furnish below particulars of the members of my family who would be eligible to receive
(For Unexempted /Exempted Establishments)
widow/children pension in the event of my death.
NOMINATION AND DECLARATION FORM S.No. Name and address Date Relationship with the
of the family members of Birth member
(Declaration and Nomination Form under the Employees' Provident Funds
(1) (2) (3) 4
and Employees' Pension Scheme)
1
(Paragraphs 33 & 61 (1) of the Employees' Provident Funds Scheme, 1952 and
paragraph 18 of the Employees' Pension Scheme, 1995) 2

1. Name (in Block letters) : 3

2. Father's/Husband's Name : 4

3. Date of Birth : ** Certified that I have no family, as defined in para 2(vii) of Employees' Pension Scheme, 1995
4. Sex : and should I acquire a family hereafter I shall furnish particulars thereon in the above form.
5. Marital Status : I hereby nominate the following persons for receiving the monthly widow pension (admissible
under para 16 2(a) (i) and (ii) of Employees' Pension Scheme, 1995 in the event of my death
6. Account No. (PF/EPS Number) : PN / 11332/ without leaving any eligible family member for receiving Pension. $$
7. Address (Residential) : Permanent
Temporary Name and Address Date Relationship with the
of the Nominee of Birth member

PART A (EPF) # (1) (2) (3)

I hereby nominate the person(s)/cancel the nomination made by me previously and nominate,
the person(s) mentioned below to receive the amount standing to my credit in the Employees'
Provident Fund, in the event of my death:

Name and Nominee’s Date of Total amount If the nominee is a

Address of relationship Birth or share of minor, name & Dated the :______________
the nominee/ with the accumulations relationship &
in Provident address of the
...……………………………………
nominees member
Fund to be guardian who may Signature or thumb impression
paid to each receive the amount
nominee (%) during the minority of of the subscriber
nominee
(1) (2) (3) (4) (5)
**Strike out whichever is not applicable.

CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by
100% Shri/Smt./Kumari__________________________________employed in my establishment after he/she has
read the entries/the entries have been read over to him/her by me and got confirmed by him/her.
Place: ________________
1. * Certified that I have no family as defined in para 2(g) of the Employees' Provident Funds Dated the ____________
Scheme, 1952, and should I acquire a family hereafter, the above nomination should be ………………………………………………………….
deemed as cancelled.
Signature of the Employer or other authorised
2. * Certified that my father/mother is/are dependent upon me.
3. * Strike out whichever is not applicable. Officer of the establishment
Designation……………………………………….
Signature or thumb impression of the subscriber Name and address of the Factory/Establishment
Note: A Fresh nomination shall be made by the member on his marriage and any or rubber stamp thereof
nomination made before such marriage shall be deemed to be invalid
$- Applicable if Married -> To Spouse and Children (include children adopted legally before death in service.
# If Married –> Spouse, Children (married or unmarried), his/her dependent parents, deceased son's widow and children.
If unmarried then Parents, Brother, Sister or any other person(s). $$- Applicable to both Married and unmarried – (1) Married ----- To any person(s) other than spouse and children.
(2) Unmarried ----- To Parents, Brother, Sister or any other person(s).

15 Page No.-1 Page No. - 2 16

 Employee Code __________
(Mandatory)

FORM 2 (Revised) Part B (EPS) (Para 18) $

I hereby furnish below particulars of the members of my family who would be eligible to receive
(For Unexempted /Exempted Establishments)
widow/children pension in the event of my death.
NOMINATION AND DECLARATION FORM S.No. Name and address Date Relationship with the
of the family members of Birth member
(Declaration and Nomination Form under the Employees' Provident Funds
(1) (2) (3) 4
and Employees' Pension Scheme)
1
(Paragraphs 33 & 61 (1) of the Employees' Provident Funds Scheme, 1952 and
paragraph 18 of the Employees' Pension Scheme, 1995) 2

1. Name (in Block letters) : 3

2. Father's/Husband's Name : 4

3. Date of Birth : ** Certified that I have no family, as defined in para 2(vii) of Employees' Pension Scheme, 1995
4. Sex : and should I acquire a family hereafter I shall furnish particulars thereon in the above form.
5. Marital Status : I hereby nominate the following persons for receiving the monthly widow pension (admissible
under para 16 2(a) (i) and (ii) of Employees' Pension Scheme, 1995 in the event of my death
6. Account No. (PF/EPS Number) : PN / 11332/ without leaving any eligible family member for receiving Pension. $$
7. Address (Residential) : Permanent
Temporary Name and Address Date Relationship with the
of the Nominee of Birth member

PART A (EPF) # (1) (2) (3)

I hereby nominate the person(s)/cancel the nomination made by me previously and nominate,
the person(s) mentioned below to receive the amount standing to my credit in the Employees'
Provident Fund, in the event of my death:

Name and Nominee’s Date of Total amount If the nominee is a

Address of relationship Birth or share of minor, name & Dated the :______________
the nominee/ with the accumulations relationship &
in Provident address of the
...……………………………………
nominees member
Fund to be guardian who may Signature or thumb impression
paid to each receive the amount
nominee (%) during the minority of of the subscriber
nominee
(1) (2) (3) (4) (5)
**Strike out whichever is not applicable.

CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by
100% Shri/Smt./Kumari__________________________________employed in my establishment after he/she has
read the entries/the entries have been read over to him/her by me and got confirmed by him/her.
Place: ________________
1. * Certified that I have no family as defined in para 2(g) of the Employees' Provident Funds Dated the ____________
Scheme, 1952, and should I acquire a family hereafter, the above nomination should be ………………………………………………………….
deemed as cancelled.
Signature of the Employer or other authorised
2. * Certified that my father/mother is/are dependent upon me.
3. * Strike out whichever is not applicable. Officer of the establishment
Designation……………………………………….
Signature or thumb impression of the subscriber Name and address of the Factory/Establishment
Note: A Fresh nomination shall be made by the member on his marriage and any or rubber stamp thereof
nomination made before such marriage shall be deemed to be invalid
$- Applicable if Married -> To Spouse and Children (include children adopted legally before death in service.
# If Married –> Spouse, Children (married or unmarried), his/her dependent parents, deceased son's widow and children.
If unmarried then Parents, Brother, Sister or any other person(s). $$- Applicable to both Married and unmarried – (1) Married ----- To any person(s) other than spouse and children.
(2) Unmarried ----- To Parents, Brother, Sister or any other person(s).

15 Page No.-1 Page No. - 2 16

 Guidance For Filling Part B (EPS) (Para 18) $
I hereby furnish below particulars of the members of my family who would be eligible to receive
The Form No. 2 widow/children pension in the event of my death.
S.No. Name and address Date Relationship with the
of the family members of Birth member
Employee's Provident Fund Scheme, 1952 (1) (2) (3) 4
(EPF)
1

2
Para 33: Declaration by persons already employed at the time of institution of the
fund :- 3

Every person who is required or entitled to become a member of the Fund shall be asked forthwith 4
by his employer to furnish and shall, on such demand, furnish to him, for communication to the
** Certified that I have no family, as defined in para 2(vii) of Employees' Pension Scheme, 1995
Commissioner, particulars concerning himself and his nominee required for the declaration form
and should I acquire a family hereafter I shall furnish particulars thereon in the above form.
in Form 2. Such employer shall enter the particulars in the declaration form and obtain the
I hereby nominate the following persons for receiving the monthly widow pension (admissible
signature or thumb impression of the person concerned.
under para 16 2(a) (i) and (ii) of Employees' Pension Scheme, 1995 in the event of my death
without leaving any eligible family member for receiving Pension. $$
Para 61: Nomination
• Each member shall make in his declaration in Form 2, a nomination conferring the right to Name and Address Date Relationship with the
receive the amount that may stand to his credit in the Fund in the event of his death before the of the Nominee of Birth member
amount standing to his credit has become payable, or where the amount has become (1) (2) (3)
payable before payment has been made.
• A member may in this nomination distribute the amount that may stand to his credit in the
Fund amongst his nominees at his own discretion.
• If a member has a family at the time of making a nomination, the nomination shall be in
favour of one or more persons belonging to his family. Any nomination made by such
member in favour of a person not belonging to his family shall be invalid. Dated the :______________
...……………………………………
• Provided that a fresh nomination shall be made by the member on his marriage and any
nomination made before such marriage shall be deemed to be invalid. Signature or thumb impression
of the subscriber
• If at the time of making a nomination the member has no family, the nomination may be in
favour of any person or persons but if the member subsequently acquires a family, such **Strike out whichever is not applicable.
nomination shall forthwith be deemed to be invalid and the member shall make a fresh
nomination in favour of one or more persons belonging to his family. CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by
• 4A Where the nomination is wholly or partly in favour of a minor, the member may, for the
Shri/Smt./Kumari__________________________________employed in my establishment after he/she has
purposes of this scheme appoint a major person of his family, as defined in clause (g) of read the entries/the entries have been read over to him/her by me and got confirmed by him/her.
paragraph 2, to be the guardian of the minor nominee in the event of the member
Place: ________________
predeceasing the nominee and the guardian so appointed.
Dated the ____________
• Provided that where there is no major person in the family, the member may, at his discretion,
appoint any other person to be a guardian of the minor nominee. ………………………………………………………….
Signature of the Employer or other authorised
• A nomination made under sub-paragraph(1) may at any time be modified by a member
after giving a written notice of his intention of doing so in form 2. If the nominee Officer of the establishment
predeceases the member, the interest of the nominee shall revert to the member who may Designation……………………………………….
make a fresh nomination in respect of such interest. Name and address of the Factory/Establishment
• A nomination or its modification shall take effect to the extent that it is valid on the date on or rubber stamp thereof
which it is received by the commissioner. $- Applicable if Married -> To Spouse and Children (include children adopted legally before death in service.

$$- Applicable to both Married and unmarried – (1) Married ----- To any person(s) other than spouse and children.
(2) Unmarried ----- To Parents, Brother, Sister or any other person(s).

17 Page No. - 2 14
 Employee Code __________
(Mandatory)

Para 2(g) : Family Means :-

FORM 2 (Revised)
(i) in the case of a male member, his wife, his children, whether married or unmarried, his
(For Unexempted /Exempted Establishments)
dependent parents and his deceased son's widow and children;
NOMINATION AND DECLARATION FORM
Provided that if a member proves that his wife has ceased, under the personal law governing him
(Declaration and Nomination Form under the Employees' Provident Funds or the customary law of the community to which the spouses belong, to be entitled to
and Employees' Pension Scheme) maintenance she shall no longer be deemed to be a part of the member's family for the purpose
(Paragraphs 33 & 61 (1) of the Employees' Provident Funds Scheme, 1952 and of this scheme, unless the member subsequently intimates by express notice in writing to the
paragraph 18 of the Employees' Pension Scheme, 1995) commissioner that she shall continue to be so regarded; and

1. Name (in Block letters) : (ii) In the case of a female member, her husband, her children, whether married or unmarried,
2. Father's/Husband's Name : her dependent parents, her husband's, dependent parents, her deceased sons's widow and
3. Date of Birth : children;
4. Sex :
Provided that if a member by notice in writing to the commissioner expresses her desire to exclude
5. Marital Status : her husband from the family, the husband and his dependent parents shall no longer be deemed
6. Account No. (PF/EPS Number) : PN / 11332/ to be a part of the member's family for the purpose of this scheme, unless the member
subsequently cancels in writing any such notice.
7. Address (Residential) : Permanent
Temporary Explanation : In either of the above two cases, if the child of a member [or as the case may
be, the child of a deceased son of the member ] has been adopted by another person and if,
PART A (EPF) # under the personal law of the adopter, adoption is legally recognised, such a child shall be
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate, considered as excluded from the family of the member.
the person(s) mentioned below to receive the amount standing to my credit in the Employees'
Provident Fund, in the event of my death:

Total amount
Employees Pension Scheme, 1995
Name and Nominee’s Date of If the nominee is a
Address of relationship Birth or share of minor, name & (EPS)
the nominee/ with the accumulations relationship &
nominees member in Provident address of the
Fund to be guardian who may Para 18 : Particulars to be supplied by the Employees already employed at the time of
paid to each receive the amount commencement of the Employees Pension Scheme.
nominee (%) during the minority of
nominee Every person who is entitled to become a member of the Employees Pension Fund shall be asked
(1) (2) (3) (4) (5) forthwith by his employer to furnish and that person shall, on such demand, furnish to him for
communication to the Commissioner particulars concerning himself and his family in the form
prescribed by the Central Provident Fund Commissioner.
100%
Para 2(vii) :- Family means :-
• Wife in the case of male member of the Employees' Pension Fund;
1. * Certified that I have no family as defined in para 2(g) of the Employees' Provident Funds • Husband in the case of a female member of the Employees' Pension fund;and
Scheme, 1952, and should I acquire a family hereafter, the above nomination should be • Sons and daughters of a member of the Employees Pension fund;
deemed as cancelled.
2. * Certified that my father/mother is/are dependent upon me. Explanation The expression “Sons” and “daughters” shall include children [ Legally adopted by
3. * Strike out whichever is not applicable. the member]

Signature or thumb impression of the subscriber NOTE : Members can nominate a person to receive benefits under the Employees' Pension
Note: A Fresh nomination shall be made by the member on his marriage and any Scheme 1995 where a member is unmarried or does not have any family. Such nominee shall
nomination made before such marriage shall be deemed to be invalid be paid pension equal to widow pension in case of death of member.
# If Married –> Spouse, Children (married or unmarried), his/her dependent parents, deceased son's widow and children.
If unmarried then Parents, Brother, Sister or any other person(s).

13 Page No.-1 18
 Employees' Provident Funds Scheme,1952
FORM 19
Form To Be Used By A Major Member Of The Employees' provident Funds Scheme,
1952 For Claiming The Employees' provident Fund Dues (Para 72(5)

1 Name of the Member (in block letters) :

2 Father's Name (or Husband's Name :
in the case of married woman)
3. Name and address of the Factory/ :
establishment in which the member
was last employed
4 Account No. :
5. Date of leaving service :
6 Reasons for leaving service :
7 Full Postal address(in Block letters) : Shri/Smt/Kumari .........................................
S/o d/o w/o ..............................................................................................................
........................................................................ Pin ..................................................
8 Mode Of Remittance :
Put a tick in the box against the one opted : [ ]
(a) by postal money order at my cost To the address given against item No. 7
(payable upto Rs. 2,000/- only) [ ]
(b) by account payee cheque sent [ ] S.B. Account No. ...............................................
for credit to my account in the Name of the Bank ..............................................
Scheduled Bank/or any post office Branch:............................................................
or any Co-operative Branch: Bank ................................................................
including Urban Co-operative Bank. Full address of the Branch: ..................................
........................................................................
........................................................................

Contribution for the current financial year

Period of Period of
Month Contribution Month Contribution
Break Break
Month Wages EE Employer Total Month Wages EE Employer Total
EPF EPF PS EPF PS EPF EPF PS EPF PS

19 12
 FORM 11 (Revised) Employee Code................. (Advance Stamped Receipt furnished below)
Mandatory Certified That The Particulars Are True To The Best Of My Knowledge
Date of joining the Establishment : .......................................................
THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952 (Paragraph 34) Date of Birth : .......................................................
AND Information to be furnished by the Employer if the Claim Form is Attested by the Employer.
Certified that the above contributions have been included in the regular monthly remittances.
THE EMPLOYEES' PENSION SCHEME, 1995 (Paragraph 24) The applicant has signed/thumb impressed before me.
Declaration by a person taking up employment in an establishment in which the Employees'
Signature or Left hand thumb
Provident Funds & Employees' Pension Scheme enforce
Impression of the member
Signature of the employer or authorised official
I .................................................................... son/wife/daughter of Sh.................................................…….
(Name of Employee) Date : ...............................................................
do hereby solemnly declare that : Designation & Seal : ............................................
(a) I was last employed in M/s ...........................................................................................................................
In case, however, the members are physically handicapped and cannot affix left thumb
(Name and Full Address of the immediate previous employer) impression, the thumb and finger impression of the right hand failing which toe impression may
be obtained.
and left service on ........................................................................................... Prior to that I was employed in Note : In the case of submission of application for settlement under clause (e) of sub-paragraph
(Date of leaving with immediate previous employer)
(I) and in clause (2) of paragraph 69 of the EPF Scheme, 1952, the Claim should be submitted
............................................................................................from..................... to .................................... after two months from the date of leaving service provided the member continues to remain un-
(Name and Full Address of the second last employer, if any) employed in an estt. to which the Act applies.
(Date of joining & leaving with second last employer, if any) Advance Stamped Receipt
(b) I was member of......................................................................................................................................... (To be furnished only in case of 8(b) above)
(Name of PF Trust / Address of PF Office of immediate previous employer) Received a sum of *Rs ................................ Rupees .....................................................only)
Provident Fund and also/but not* of the Pension Fund from............................. to .................................... from Regional Provident Fund Commissioner/ Officer-in-charge of Sub-Regional Office/Sub-
(Date of joining & leaving with immediate previous employer). Accounts Office...........................................................By deposit in my saving Bank account
and my account number (s) was/were ...............................................................................................
towards the settlement of my Provident Fund Account.
(PF No. with Establishment Code of immediate previous employer)
(c) I have/ have not* withdrawn the amount of my Provident Fund /pension Fund.
The space should be left blank which shall be filled in by
(d) I have/have not*drawn any superannuation benefits in respect of my past service from any employer. Regional Provident Fund Commissioner/Officer in-charge
(e) I have/have never*been a member of any Provident Fund and/or Pension Fund. of S.R.O./S.A.O.
(f) I am drawing / Not drawing* Pension under EPS 95.
(g) I am a holder/not holder* of scheme Certificate. Signature or Left hand thumb impression of the member
((h) Scheme certificate surrendered/not surrendered*.
For the use of Commissioner's Office
*Strike out whichever is not applicable. A/c. Settled in Part/Full Entered in F.21-A/24/2/9 (Revised) & Withdrawal register
.........................................Clerk........................................S.S.........................................
______________________
(Under Rupees.......................................) Account No..................................
Date : .......................... Signature of left hand
impression of the employee P.I.No...................................................................
Nature of benefit..................................
________________________________________________________________________________________________ Section................................................ MO/Cheque........................................
Shri/Smt.________________________________is appointed as ____________________________________________ Passed for Payment for Rs.......................................
(Name of Employee) (Designation with Co.) (in words) (Rupees.................................................)
MAX INDIA LIMITED
in M/s______________________________________with effect from ________________________________ Money order Commissioner (if any) A.A.O./A.P.F.C.
(Name of the Present employer) (Date of appointment Net Amount to be paid by MO Rs............................................ Date ....................................
[For use in Cash Section]
P.F. Account Number PN/11332
___________________________________
(PF No. with Estt. Code of Present Employer) Paid by inclusion in Cheque No. ...................................... Dated .........................................
vide Cash Book (Bank) Account No. 3 Debit Item No. ...........................................................
___________________
Date : ______________________ _____________________________________ ............................S.S..........................AAO/APFC...........................RPFC........................
(Date of joining of employee) Signature of the Employer/Manager or Other
authorised Officer with Office Seal Remarks

Form 11 Acknowledgment received on ................................................

Verified on ...........................................

11 20
 FORM 10-C (EPS)

Employees' Pension Scheme, 1995

Form to be used by a member of the
Employees' Pension Scheme, 1995 for Claiming
Nomination For Group Term Life Cover
Withdrawal Benefit / Scheme Certificate

1. a) Name of the member :

( in block letters )
b) Name of the claimant(s) :
DD MM Y Y Y Y
2. Date of Birth :
3. a) Father's Name :
b) Husband's Name :
(if applicable)
4. Name & Address of the Establishment :
in which, the member was last employed

5. Code No. & Account No. Region/SRO Code Estt. Code A/c No.

6. Reason for leaving service :

& Date of leaving

7. Full Postal Address : ....................................................................

(In Block letters) ....................................................................
....................................................................
Pin: ..............................................................

8. Are you willing to accept Scheme (a) (b)

Certificate in lieu of withdrawal benefits Yes No

9. Particulars of Family (Spouse & Children & Nominee)

Name Date of Relationship Name of the Guardian
Birth with member for minor
a) Family members
b) Nominee

..................................................................................................................................

10. In case of death of member after attaining the :

age of 58 years without filing the claim

a) Date of death of the member

b) Name of claimant (s)/ and relationship :

with the member

21 10
 11. Mode Of Remittance [put A Tick In The Box Against The One Opted]

a) By postal money order at my cost to the

address given against item No. 7
Nomination For Group Term Life Cover
b) Account payee cheque sent direct for credit to
my SB A/c (Scheduled Bank) under intimation to me)

Employee Name : ................................................................................. S.B. Account No. : ...........................................................................

Location : ................................................................................. Name of the Bank : ...........................................................................

(In Capital letters)

Designation : ................................................................................
Branch : ..........................................................................
(In Block letters)
Date of Joining : ................................................................................

Full address of the Branch : ..........................................................................

(In capital letters)
..........................................................................
Proportion by which the
Name Relation Date of Birth
sum Insured will shared
..........................................................................

12. Are you availing Pension under EPS, 1995 ? if so,

Indicate PPO No. ............................. By whom issued ? ...............................................

Certified That The Particulars Are True To The Best Of My Knowledge

Dated .......................………….
Place : ................................... Signature or left Hand
Thumb impression of the
member/Claimant(s)
Date : .............................. ....................................................................

Signature / thumb impression of the employee

9 22
 Advance Stamped Receipt
(To be furnished only in case of 11 (b) above)

Received a sum of Rs.* ....................................... ( Rupees ..................................................

..................................only) from Regional Provident Fund Commissioner/Officer-in-charge of
Sub-Regional Office, ............................................ by deposit in my Savings Bank A/c towards
the settlement of my Pension Fund Account.
*(The space should be left blank which shall be filled by Regional Provident Fund
Commissioner/Officer-in-charge)

Signature or left hand thumb impression of the member on the stamp

Re.1
Revenue
stamp

Attestation Of Employer
Certified that the particulars of the member Shri/Smt./Kum. ...................................................
A/c No. .......................... are correct and the member has signed/thumb impressed before me
The details of wages and period of non-contributory service of the member are as under:-
( Form 3-A/7 (EPS) enclosed for the period for which it was not sent to Employees' Provident Fund
Office.)
Wages (Basic + D.A.) as on 15.11.95 ( if applicable) :
Wages as on the date of exit :

Period of non-contributory service

Year/Month No.of days
Signature of Employer/
Authorised Offical
with seal
Date :

23 8
 Career For Life @ Max Life Insurance

Statement Of Compliance With (For The Use Of Commissioner's Office)

Business Conduct Standards

Max Life Insurance Limited
Appendix Forms

( Under Rs. ......................................................................................................................

P.I. No. .................................................................... M.O. / Cheque ................................

I have been briefed and I've reviewed the Company's Business Conduct Standards. I certify that I
agree with the principles contained in Business Conduct Standards, and will adhere to all Passed for payment for Rs. .................................................................................................
standards contained within.

M.O. Commission (if any) ............................ net amount to be paid by M.O. .........................
...................................................................................
Signature .............................................................. towards withdrawal benefit.

................................................................................. D.H. ...................................... S.S. .......................................... A.A.O ..............................

Name

(For Use In Cash Section)

..................................................................................
Department
Paid by inclusion in cheque No. ......................................... Date .................................. vide

..................................................................................
Date cash Book (Bank) Account No. 10 Debit item No. .................................................................

.................................................................................. ..............................................................S.S.................................................... AC(CASH)

Manager
For issue of S.C.; IDS is enclosed with Form 2 (Revised).

D.H. ........................ S.S....................................A.A.O.................................... APFC(A/cs)

(For Use In Pension Section)

Scheme Certificate bearing the Control No. ..........................................................issued on

..................................................And entered in the Scheme Certificate Control Register:

D.A. S.S. A.A.O. APFC(PENSION)

7 Max Life Insurance / Human Resources New Employee Code 24

 Career For Life @ Max Life Insurance

Payment of Gratuity (Central) Rules, 1972 Terms & Conditions / / / /

Form F: Nomination
12. In the event of the employee committing breach of any terms and conditions contained

Appendix Forms
[Sub-rule (1) of rule 6]
herein, the employer reserves the right to take suitable action / and pursue such remedy as it
To deems fit.
(Give name or description of the establishment with full address)
1. I, Shri/ Shrimati/ Kumari ...............................................(name in full) whose particulars
are given in the statement below, hereby nominate the person(s) mentioned below to receive
the gratuity payable after my death as also the gratuity standing to my credit in the event of Signed and delivered by the Employee
my death before that amount has become payable, or having become payable has not been
paid and direct that the said amount of gratuity shall be paid in proportion indicated against
the name(s) of the nominee(s). .........................................................................................
2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within the (Signature)
meaning of clause (h) of section 2 of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the said
Act. Name : ......................................................................
4. (A) My father/ mother/ parents is/ are not dependent on me.
(B) My husband's father/ mother/ parents is/ are not dependent on my husband.
Place : ......................................................................
5. I have excluded my husband from my family by a notice dated the __________ to the
controlling authority in terms of the proviso to clause (h) of section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.
Date : ......................................................................
NOMINEE(S)

Name in full with full Relationship with Proportion by which the

Age of nominee
address of nominee(s) the employee gratuity will be share
In the presence of :
(1) (2) (3) (4)

1.

2. ............................................................................ (Witness)

3. (Signature) Affix passport

size photograph

4.

Name : .......................................................................

Address : .......................................................................

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 Career For Life @ Max Life Insurance

Statement
Terms & Conditions 1. Name of employee in full ............................................................................................
Appendix Forms

9. The Employee shall not bind the Company against a third party, in any manner whatsoever,
2. Sex ..........................................................................................................................
thereby creating pecuniary or other obligations, without prior authorization in writing. The
Employee will exercise his/her best efforts to conserve the resources of the Company and 3. Religion ....................................................................................................................
incur expenses judiciously and certainly within the authorized limits.
4. Whether unmarried / married / widow / widower ............................................................
10. The Employee further agrees that his/her employment shall be subject to the following
conditions : 5. Department / branch / section where employed .............................................................
10.1. No person whose employment is contemplated to be regular shall be taken into the 6. Post held with ticket or, serial no., if any ..........................................................................
organization of the Company as a regular employee until the probationary period as
7. Date of appointment ..................................................................................................
hereinafter described, shall have elapsed.
10.2. Any such employee may be discharged by the Company at any time during such 8. Permanent address ....................................................................................................
probationary period by the giving of 15 days' notice or on payment of 15 days' TEC in
effect at the time of separation in lieu of notice. Village.......................................... Thana.......................................... Sub-division..................................
10.3. If a person has completed the period of probation but has not been dismissed and
cannot in the view of the Company be confirmed as at the end of probation he/she Post Office.................................... District......................................... State.............................................
shall continue to be on probation till such time as his/her services are confirmed in
writing and on confirmation, he/she shall be deemed to have attained a regular Place...........................................
status of employment but the beginning thereof shall be the date of his/her Date............................................
employment.
Signature / thumb impression of the employee
10.4. In the event of resignation/discharge from employment at any time within the first
three years of employment with the Company, the Employee shall not take Declaration by Witness
employment with any other entity/company/organization having similar business Nomination signed / thumb-impressed before me.
interests for a period of six months from the date of relieving/discharge. In the above
eventuality, the Employee recognizes his/her responsibility to disclose this provision to Name in full and full addresses of witnesses. Signature of witnesses

the prospective employer and acknowledging this to be a reasonable restriction

1. 1.
agrees and understands that the Company will have the right to inform the other
entity/company/organization of this provision. 2. 2.
10.5. In the event of resignation/discharge from employment, the Company reserves the
right to process/settle Provident Fund withdrawal accumulations of the employee and
credit the same to the employees bank account in case the employee does not initiate
transfer or withdrawal process within 60 days from his last working day.
11. The Company will give to any person who has attained a regular status of employment one
month's notice for discharge or the Company may pay to such an employee, one month's
TEC then in effect or a proportionate amount in lieu of notice. The Company, however,
reserves the right to have the discharge take effect immediately if such discharge is brought
about by dishonesty, disloyalty, insubordination, moral turpitude or other good cause,
including breach of any of the above conditions, without prejudice to any other rights and
remedies of the Company. Nothing hereinabove contained will have effect or will operate
to the prejudice and detriment of or in derogation of any rights or privileges conferred on the
Employee by any applicable award for the time being in force or any other law or contract
with the Company.

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 Career For Life @ Max Life Insurance

Certificate By The Employer Terms & Conditions

Certified that the particulars of the above nomination, have been verified and recorded in this
establishment. 3. General Covenants

Appendix Forms
The Employee shall not engage, directly or indirectly, in any other gainful or commercial
Employer's reference no., if any Signature of the employer / officer
authorised Designation employment, activity or business for profit during the Employment. The Employee shall
honestly and faithfully conduct himself/herself and duly and diligently perform all the duties
............................................................. .............................................................
devolving upon him/her in the course of employment of the Company. The Employee will
devote the whole of working time in the work of the Company and use his/her best
Name and address of the establishment /
rubber stamp therof endeavors to promote the interests and welfare of the Company.

4. The Employee will truly and faithfully account for and deliver to the Company all moneys,
securities and other property belonging to the Company which he/she may from time to
time receive for, from or on account of the Company and that upon cessation of the
Date..................................................... employment, he/she will at once deliver to the Company all notes, data, tapes, reference
items, books, documents, effects, money, securities or other property belonging to
the Company or for which the Company is liable to others.
Acknowledgment By The Employee
5. The Employee shall be bound by all the rules, regulations and policies, including without
limitation the Business Conduct Standards of the Company, now in force and by all such
Received the duplicate copy of nomination in Form F filed by me and duly certified by the
other rules and regulations as may be hereafter passed and called to his/her notice and that
employer.
the Employee will faithfully observe and abide by the same.

6. The Employee shall not use any of the Company's facilities or Confidential Information to
enter into speculative trading of any kind either on his/her account or that of another person
or entity. The Employee will not enter into any transaction with other competitors of the
Company (life insurance companies), which may adversely affect the business interests of
Date ........................................ Signature of the employee the Company.

7. THAT, during his/ her employment with the Employer, the Employee shall hold himself/
herself in reasonable readiness to move to any of the offices/divisions/departments whether
existing or to be set up, in the same town where the Employee is currently employed or
anywhere else in India or overseas at the sole discretion of the employer on the terms and
conditions of employment applicable in the place of posting. This move may be within the
employer or to another firm/company which is an associate or sister company or wherein
the employer has business interest either financial or managerial, provided that the total
emoluments drawn and benefits applicable at the time of such move are not adversely
affected in any manner.

8. FURTHERMORE, should the Employee decide to resign from the services of the Company,
he/she shall notify the concerned functional head in writing at least 30 days in advance.
However in case of a probationer the notice period shall be 15 days. Failure to give such
notice or quitting before the expiry of such notice shall result in forfeiture of the
proportionate total employee cost (“TEC”) then in effect, in lieu of such notice being given to
the Company. However, the Company may at its discretion relieve the said employee
before expiry of the requested notice period and in such an event, no salary in lieu of notice
is payable or recoverable to/from the employee.

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 Careers For Life @ Max Life Insurance

Terms & Conditions Medical Insurance Coverage Form

1. Confidentiality
1.1.The Employee will at all times observe the strictest confidentiality regarding all Employee Name
Appendix Forms

Confidential Information pertaining to Max Life Insurance Company Limited Employee Code
(“MLI” or the “Company”), its affiliates, third party contractors, vendors, Location
consultants or service providers. For this Agreement Confidential Information
shall mean, all information or data (in any form or medium) disclosed to the
Employee by the Company or by a third party acting on behalf of the Company Details of Self & Family (For Coverage under Medical Insurance Scheme)
and shall include without limitation Particulars Name DOB/ Age Gender
(a) any information ascertainable by inspection or analysis of samples; (b) any Employee Name
information having been disclosed prior to the date hereof; and (c) any Spouse Name
information relating to the Company's business operations, underwriting
standards, actuarial data, processes, business plans, intentions, product Child 1 - Name
information, product documentation, product plans, investments, know-how, Child 2 - Name
rights, trade secrets, customer lists, market opportunities, business affairs,
computer programs, hardware configurations, engineering specifications, and
other business practices. Additional coverage allowed on payment basis only
(One time premium deduction is done directly from the salary on pro-rata basis)
1.2.The Employee agrees and covenants with the Company:
Particulars Name DOB/ Age Gender
1.2.1. To use the Confidential Information, solely for the purpose of executing
duties in the course of employment and for no other purpose and in particular, Father's Name
but without prejudice to the generality of the foregoing, (i) not to make any Mother's Name
commercial use thereof (ii) not to use the same for the benefit of himself/herself
or of any third party; and for any purpose whatsoever, without the prior written
consent of the Company; Important:
1. Insurance coverage is not extended beyond two children, not even on payment basis.
1.2.2. Not to disclose any Confidential Information to any third party. Disclosures
2. Insurance does not cover brother, sister (above 18 years) and In-laws.
of Confidential Information shall be strictly on a need to know basis and in
accordance with the policies of the Company; 3. Insurance renewal date is on 1st of December every year
4. For any clarification on coverage please contact
1.2.3. Not to copy, reproduce, reverse engineer, disassemble, modify and/or
replicate in any manner, the Confidential Information or any part thereof, Medical Insurance email ID : [email protected]
without the prior written consent of MLI; 5. You can take print-out of your ecard from Max Bupa Protal - http://healthlink.maxbupa.com

1.2.4. To return all Confidential Information and materials based thereon (and
all copies thereof) containing Confidential Information immediately on cessation
of employment for any reason whatsoever.

2. Ownership Of Intellectual Property Rights

MLI shall retain all ownership in and to any Confidential Information that is disclosed
by it hereunder including all improvements, modifications or derivative works of its
Confidential Information and/or any patents, copyright or other intellectual property
rights therein. Employee agrees and undertakes that he/she will not have any
proprietary rights in any Confidential Information or other Intellectual Property Rights
disclosed to the Employee during the term of this Employment. Further, the
proprietary rights in any derivative works developed by the employee based on any
Confidential Information or Intellectual Property Rights shall vest with MLI, as an
employer.

3 Max Life Insurance / Human Resources New Employee Code 28

 Career For Life @ Max Life Insurance

List of Forms
Appendix - Forms

Appendix Forms
• Terms & Conditions of Employment
• Nomination for Group Term Life Cover 9
• Form 11 (Revised) - Employees' Provident Funds Scheme, 1952 11
• Form 2 (Revised) Nomination & Declaration Form 12
• Form 19 - Employees' Provident Funds Scheme, 1952 17
• Form 10-C Employees' Pension Scheme, 1995 19
• EPF Form for Allotment of Social Security Number (SSN) 23
• Payment of Gratuity (Central) Rules, 1972 26
• Medical Insurance Coverage Form 30

29 Max Life Insurance / Human Resources New Employee Code 2

 Careers For Life @ Max Life Insurance

Check List
Have you completed your documentation …
Appendix Forms

• Submission Of Documents
9 Curriculum Vitae (CV)
9 Application Sheet of Max Life Insurance
9 Copy of Accepted Resignation / Copy of Resignation Letter Submitted
9 Copy of previous Salary Slips / Most recent Salary Revision document
9 Experience Certificate
9 Copy of Educational Certificates
9 Copy of Acceptance Offer
• Completion Of Forms
9 Terms & Conditions of Employment
9 Statement of Compliance with Business Code Of Conduct
9 Group Medical Insurance Scheme
9 Nomination for Group Term Life Cover
9 Form 11 (Revised) - Employees' Provident Funds Scheme, 1952
9 Form 2 (Revised) – Nomination & Declaration Form (Fill in DUPLICATE)
9 Form 19 - Employees' Provident Funds Scheme, 1952
9 Form 10-C – Employees' Pension Scheme, 1995
9 EPF – Form for Allotment of Social Security Number (SSN)
9 Payment of Gratuity (Central) Rules, 1972
• Getting Started Forms
9 Employee ID
Will be generated within three days of your submitting the joining report
9 E-mail ID generation
9 Opening of Bank account
Collect Form from HR/Zonal HR/Office Coordinator (in case separate form
not in handbook)
Within 10 working days after submission of form you should receive your bank
account number along with Debit Card from the bank
9 Tax Consulting
9 It is important for you to speak to the tax consultant within a month of your joining
9 Visiting Cards Request
9 How to claim MOS bills
• BRE Declaration

1 Max Life Insurance / Human Resources New Employee Code 30