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Insurance
(Please enter in BLOCK LETTERS)
Employees
Mr./Mrs./ Ms:
Name :
FIRST NAME
MIDDLENAME
SURNAME
Employee
No:
Designation
:
Marital
Status:
Date of
Joining:
Date of birth:
Grade:
Date of
Marriage:
Department/
Team:
Mobile No:
Email Id:
Name
Gend
er
Date Of
Birth
Ag
e
Relationshi
p
Occupatio
n
1
2
3
4
5
I certify that the particulars mentioned above are true to the best of my knowledge
and belief.
Date
: ________________
Signature: _____________________
Tear off You may cut along this line and keep details displayed below for your
reference
Escalation matrix 1st Level Raghu (FHPL) 09223329003, 2nd Level Santosh
(Almondz) 09004050205
FAQ and Details on the medical insurance cover as applicable to you are available on
the intranet (connectGSK). If you do not have access to the intranet, please request
your line manager for the details
You will receive the cashless insurance cards about 3 months from date of joining on
your GSK email id
List
of
network
hospitals
is
available
online
at:
https://www.fhpl.net/NetworkHospitals/NWHospitals.aspx
Please note that this form can be used by existing employees to update their dependent
details.