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OPTION FORM GIVEN BELOW MAY BE COPIED AND PRINTED

                                                         CLICK (1)        CLICK (2) 

 Life Insurance Corporation Of India
Office Servicing Department
Divisional Office 

OPTION FORM FOR INCREASED FAMILY FLOATER MEDICALIM COVER.

Name of Employee

S R No                                      Department/office

Basic Pay as at 01.04.2017                                     (In case of In Service employees)

Date of retirement                                                      (In case of In retired employees)

Category Applicable

Covered for compulsory family floater sum assured Rs.

I, along with my family members, who have been covered under group Medicalim policy as per rules.opt for the increased Family Floater sum insured (compulsory +additional)of
Rs.--------  Lakh w.e.f 01.04.2018 in terms of C.O. cir No. CO/PER/ER/-A/164/2017 Dated.23.09.2017.
I, further certify that I have carefully gone through and understood the contents of this circular and shall abide by all the provisions of this circular and any subsequent modifications in terms and conditions in this regard.

I confirm that this option is irrevocable i.e  can not be revoked by me .


Signature of Employee/Retired Employee.
Date:
Place:
Mobile No.


Signature of Witness:-
Name
Address
Date
Place
______________________________________________________________________________________
                                            FOR  OFICE USE  ONLY

1.Existing Compulsory Family Floater Sum insured of the employee/retired employee Rs.
2.No.of family members of the employee/retired employee covered under Group Mediclaim scheme------
3.Total floater sum insured as per the option given vide cir No. CO/PER/ER/-A/164/2017 Dated.23.09.2017. Rs.
4.Total premium recoverable/chargeable from the  employee/retired employee Rs.

                                                                                           
                                                                                                  Signature of AO of OS Dept.