Beneficiary Nominations
Group Term Life Insurance & Group Personal Accident & *Death whilst in service
Employee’s Full Name: ___________________________________________________________________________________
Employee Code: _________________________________________________________________________________
Contact Number: _________________________________________________________________________________________
I hereby nominate the person(s) / cancel the nomination made by me previously and nominate the person(s) mentioned below to
receive the amount under GTL (Group Term Life) / GPA (Group Personal Accident)
Nominee Details
If the nominee is a minor, name & address of
Share % of
Full Name Relationship Age the guardian who may receive the amount
total 100%
during the minority of the nominee
Nomination under Death whilst in Service*, in the event of my death.
I hereby nominate Mr./Miss.______________________________________________________ to receive leave encashment or any
due salary, if applicable in case of my death.
Full Name Signature
Witness 1
Witness 2
Employee Signature ________________________________
Date: ____________________________________________
Place: ___________________________________________
EMPLOYEE
CODE :-
FORM 'F'
[See sub-rule (1) of rule 6]
Nomination
poonawallafincorp
To ……………………………………………………………………………………………………………..
[Give here name or description of the establishment with full address]
Employee name
I. Shri/Shrimati/Kumari …………………. whose particulars are given in the statement below,
[Name in full here]
hereby nominate the person(s) mentioned below to receive the gratuity payable after my death as
also the gratuity standing to my credit in the event of my death before that amount has become
payable, or having become payable has not been paid and direct that the said amount of gratuity
shall be paid in proportion indicated against the name(s) of the nominee(s).
2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within the
meaning of clause (h) of section (2) of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of section (2) of the
said Act.
4.
(a) My father/mother/parents is/are not dependent on me.
(b) my husband's father/mother/parents is/are not dependent on my husband.
5. I have excluded my husband from my family by a notice dated the to the Controlling
Authority in terms of the proviso to clause (h) of section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.
Nominee(s)
it's total should be 100 %
Name in full with full Relationship with the Age of nominee Proportion by which
address of nominee(s) employee the gratuity will be
shared
1. AAA Father 58
2. BBB SON 8
3. CCC wife 28
so on. DDD Mother 45
Statement
1. Name of employee in full. Employee name
2. Sex. Male
3. Religion. ABC
4. Whether unmarried/married/widow/widower. Married
5. Department/Branch/Section where employed. 123
6. Post held with Ticket or Serial No., if any. Employee code
7. Date of appointment. Date of joining
8. Permanent address. AAA BBB CCC
AAA AAA AAA AAA
Village ……………… Thana ……………… Sub-division ………………. Post Office ………………
AAA AAA
District ………………. State…………………
Signature
Place ABC Signature/Thumb impression
Date Doj DO NOT FILL BELOW THIS of the employee
Declaration by witnesses
Nomination signed/thumb impressed before me.
Name in full and full Signature of witnesses.
Address of witnesses.
1. 1.
2. 2.
Place
Date
Certificate by the employer
Certified that the particulars of the above nomination have been verified and recorded in this
establishment.
Employer's Reference No., if any.
Signature of the employer/
officer authorised
Designation
Date Name and address of the
establishment or rubber stamp
thereof.
Acknowledgement by the employee
Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the
employer.
Signature
Date Doj Signature of the employee
(FORM 2 REVISED)
NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS
Declaration and Nomination Form under the Employees Provident Funds and Employees Pension Schemes
(Paragraph 33 and 61 (1) of the Employees Provident Fund Scheme 1952 and Paragraph 18 of the Employees
Pension Scheme 1995)
AAA AAA AAA
1. Name (IN BLOCK LETTERS) : _______________________________________________________________________________
Name Father’s / Husband’s Name Surname
dd-mm-yyyy
2. Date of Birth : ___________________ 123
3. Account No. ___________________
married
male
4. *Sex : MALE/FEMALE: ______________________ 5. Marital Status ________________________________________
city name state
building Or home No
6. Address Permanent / Temporary : _____________________________________________________________________________
pincode
________________________________________________________________________________
PART – A (EPF)
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned below
to receive the amount standing to my credit in the Employees Provident Fund, in the event of my death.
If the nominee is minor
Name of the Address Nominee’s Date of Total amount or share of name and address of the
Nominee (s) relationship with Birth accumulations in guardian who may receive
the member Provident Funds to be the amount during the
paid to each nominee minority of the nominee
1 2 3 4 5 6
AAA AAA city & state wife dd-mm-yyyy 50%
AAA AAA city & state Father dd-mm-yyyy 50%
1 *Certified that I have no family as defined in para 2 (g) of the Employees Provident Fund Scheme 1952 and should I
acquire a family hereafter the above nomination should be deemed as cancelled.
2. * Certified that my father/mother is/are dependent upon me.
signature
Strike out whichever is not applicable Signature/or thumb impression
of the subscriber
PART – (EPS)
Para 18
I hereby furnish below particulars of the members of my family who would be eligible to receive Widow/Children Pension in the
event of my premature death in service.
Sr. No Name & Address of the Family Member Age Relationship with the member
(1) (2) (3) (4)
2 ABC 28 wife
Certified that I have no family as defined in para 2 (vii) of the Employees’s Family Pension Scheme 1995 and should I acquire a
family hereafter I shall furnish Particulars there on in the above form.
I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2 (a) (i) & (ii) in the
event of my death without leaving any eligible family member for receiving pension.
Name and Address of Date of Birth Relationship with member
the nominee
family member
city & sate building & House No dd-mm-yyyy
pincode
Date ___________________
signature
Signature or thumb impression
of the subscriber
DO NOT FILL BELOW THIS
____________________________________________________________________________________________________________
CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed / thumb impressed before me by Shri / Smt./
Miss_________________________________________________________________ employed in my establishment after he/she has
read the entries / the entries have been read over to him/her by me and got confirmed by him/her.
Date : _____________________ Signature of the employer or other authorised officer of the
establishment
Place :
Name & address of the Factory /Establishment
Date :
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