ANNEXURE - I (New Health Insurance Scheme ordered in G.O.Ms. No. 430, Finance (Salaries) Department, dated 10.9.2007) 1. Name of the Employee 2. Designation 3.a. Type of Office: Government/Local Bodies/ Public Sector Undertakings & Statutory Boards/Universities 3.b. Office in which employed 4. Date of Birth 5. Date of Retirement 6.a. Pay Drawing Office attached 6.b. Designation of the Pay drawing Officer & Code 6.c. Location of Sub-Treasury/Treasury/PAO attached 7. Employee code : ** 8.a. General Provident Fund Account No. in respect of Govt. employees 8.b. In case of new applicants state whether application for enrolment in the Contributory Provident Fund scheme has been sent to Accountant General with details of reference no. and date. Employee code of other organisations, if any assigned shall be indicated along with the identification of the Organisation ** In case the spouse is employed, the details of Organisation I which the spouse is employed shall also be furnished. Name Age as on 1.1.2008 Relationship to the employee Marital status Employment status Stamp size photograph @ (i) (ii) (iii) (iv) (v) (vi) @ The employee may furnish a joint photograph of the family in lieu of stamp size photograph of each member of the family. The details furnished by the employees shall be posted on the website by the Pay Drawing Officers. ** Employee code and organisation code of organisations other than Government Departments shall be designed by the respective organisation with a suitable Prefix identifying based on the Provident Fund Scheme inforce in the respective organisation. Signature of the Employee /True copy/ SECTION OFFICER.
