Group Personal Accident Insurance Scheme
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1KERALA STATE INSURANCE DEPARTMENT
GROUP PERSONAL ACCIDENT INSURANCE SCHEME
FORM I
See Section 9(1)
Name of Employee
: ............................................................................................................................................................. PEN/KSID ID ...............................................
Designation
: ..........................................................................................................................................
Office
: ...........................................................................................................................................................................................................................................
To *
.......................................................................................................................................................................................
I do hereby inform the ………………………………………………………………………………………………………………………….. (Designation of Head of Office) that the person(s) mentioned
hereunder shall be my Nominee(s) and that the benefits due to me under the Personal Accident Insurance Scheme to Government Employees and Teachers shall be given
to them in the following proportions (in the event of my death or incapacitated to receive the benefit).
Relationship
Proportion
Contingency under which
Person whom the amount is to
Sl. No.
Name of Nominee
Age
Address
with the
of benefits
the nomination becomes
be given if the nominee is a
member
to be given
ineffective
minor
1
2
3
4
5
6
7
8
Place :
Countersigned :
Signature :
Date :
Head of Office/Head of District Office
Name of Employee :
*Officer of the Insured mentioned in Section 5
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