REGISTER - 1

PROFORMA FOR REGISTER OF MEMBERS

GROUP INSURANCE SCHEME (JANASHREE BIMA YOJANA)

Name and Address of the Nodal Agency ______________________________________________


Sr.
No.		 Full Name
&
Address of the Member		 Sex
M/F 		Name of
Father/Husband 		Date of
Birth
&
Age at
Entry 		Name of Nominee,
Age and relationship
with Member 		Date
&
Registration
No. 		Date of
coverage under
the Scheme * 		Remarks
(1) (2) (3) (4) (5) (6) (7) (8) (9)
















               

* Note : This is the date of the 1st day of the calendar month, following the month during which premium is deposited with the LIC.