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.