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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 />

40

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