prospectus download - Uckkr.org
prospectus download - Uckkr.org
prospectus download - Uckkr.org
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(ANNEXURE-IV)<br />
GROUP PERSONAL INSURANCE OF STUDENT PROPOSAL/NOMINATION PROFORMA<br />
(To be filled by the student)<br />
1. Name and Address of Prosposer : Dean Students Welfare, Kurukshetra University,<br />
Kurukshetra.<br />
2. Name and Permanent Address of the Student ………………..……<br />
3. Father’s Name …………………………………..<br />
4. Class and Section ………………………………..<br />
5. Class Roll No. …………………………….……..<br />
6. Any Disability (Please specify) ………………………………..<br />
7. Period of Insurance : 2014-15 (01.08.14 to 31.07.15)<br />
8. Sum Insured …………………………….Rs. One Lac<br />
9. Name and Complete Address of Nominee/Assignee ………………………………<br />
……………………………………………………………………………………...<br />
Relation with Insure …………………………………………………………….…<br />
I declare that the above information is true the best of my knowledge and belief and that I have disclosed<br />
all particulars affecting the assessment of the risk. I agree that this proposal and declaration shall be the basis of<br />
the contract between me and the company. I also declare that I do not suffer from any disability other than<br />
described above.<br />
Place…………….<br />
Dated……………<br />
Signature of the student<br />
Countersigned<br />
Chairperson,<br />
Dated:……………<br />
Department of Tourism & Hotel Mgt.<br />
Kurukshetra University, Kurukshetra.<br />
---------------------------------------------------------------------------------------------------------------------<br />
ADDRESS SLIPS<br />
PLEASE WRITE YOUR NAME AND MAILING ADDRESS IN THE THREE PLACES BELOW :<br />
1. __________________________________________________<br />
__________________________________________________<br />
__________________________________________________<br />
__________________________________________________<br />
2. __________________________________________________<br />
__________________________________________________<br />
__________________________________________________<br />
__________________________________________________<br />
3. __________________________________________________<br />
__________________________________________________<br />
__________________________________________________<br />
__________________________________________________<br />
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