FORM 4A : Family Identity Card
[Regulation 95A]
Insurance No…………………………………..
Name of insured person…………………………………………..
Sex…………………………….
Son/daughter/wife of………………………………………….
Address…………………………………………………………………………………………………………………………
Dispensary…………………………………………………………………………………
PARTICULARS OF MEMBERS OF FAMILY
|
Sl. No. |
Name |
Date of birth |
Relationship with the insured person |
Identification marks |
|
1 |
|
|
|
|
|
2 |
|
|
|
|
Prepared by:
Signature or thumb-impression
of the insured person
