NOMINATION FORM FOR GOOD HEALTH PERSONAL ACCIDENT COVER ONLY

(To be sent in duplicate to The New India Assurance Company Limited, Divisional Office 712500,   Mount Casa Blanca Building, 2nd Floor, 260 Anna Salai (Near Anand Theatre), CHENNAI-600 006)

I/We the policy holder(s) under Personal Accident Policy with Policy No. 71250034                                   

and Certificate No. 712500/                    /GH                   valid for the period from                                      

to                                               do hereby assign the monies payable by The New India Assurance Co.Ltd.,

in the event of my/our death to the below mentioned person(s) and I/We further declare that the receipt given by

the nominee(s) shall be sufficient discharge to the insurance company.

Sl.
No		 Name of the Insured Person Nominee's Name Date of
Birth of
Nominee		 Relationship
to the insured Person		 Signature of
the Insured
person **		 Signature of
Witness
             
             
             
             
             
             


Name and Address of the Witness                                                                                                                                

                                                                                                                                                                                    

Incase of Minor Nominee :                                                                                  

Name and Address of Guardian and Relationship with Minor                                                                                        

                                                                                                                                                                                   

** (incase of minor insured person, guardian should sign)

Acknowledgement by The New India Assurance Company Ltd., Divisional Office 712500

 

Signature                                                                                            Date                            Seal