Sent by P. Ramanathan to OS, Chennai D O 1 of L I C of India on March 03, 2016 :
LIFE INSURANCE CORPORATION OF INDIA
Office Services Department
Office : Chennai D O 1, MADRAS - 2.
OPTION FORM FOR INCREASED FAMILY FLOATER MEDICLAIM COVER
Name of the employee / retired employee : P. RAMANATHAN
S R No. : 510396
Pension File ID No. : 770100195
Date of retirement : May 31, 1996
Applicable category :
I Covered for compulsory family floater sum assured of ₹6 lakh
My family members and I, who are
already covered for ₹20 lakh by the Group
Mediclaim Policy of L I C of India as per rules,
opt for the increased family floater sum assured (compulsory + additional) of ₹30 lakh with effect from 01/04/2016 in terms of Circular No.CO/PER/ER-A/115/2016 dated 12/02/2016 of the Central Office of the Corporation.
I further certify that I have gone through and understood the contents of the said circular and shall abide by all of its provisions and any subsequent modification in terms and conditions in this regard.
I confirm that this option is irrevocable, i.e., cannot be revoked by, me except in terms of the Circular No.CO/PER/ER-A/120/2016 dated 26.02.2016. Particulars of the members of my family covered under the Group
Mediclaim Scheme of the Corporation are as under :
1. P. Ramanathan Self
2. M. Shantha Ramanathan Spouse
P. Ramanathan
Signature of the retired employee :
Place : MADRAS - 24. Date : March 02, 2016
FOR OFFICE USE ONLY
1. Existing compulsory Family Floater Sum Assured of the retired employee : ₹
2. Number of members of family of the retired employee covered under Group
MEDICLAIM Scheme :
3. Total Floater Sum Assured as per the option given, vide Circular No.CO/PER/ER-A/115/2016 dated 12.02.2016 : ₹
4. Annual premium per member : ₹
5. Total premium deductible / chargeable from the retired employee : ₹
(Signature of A.A.O / A.O. of O S Dept.)
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