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Yuva Raksha Insurance Registration Form

This document contains a registration form for a group insurance scheme called "YUVA RAKSHA" for students. The form collects information such as the student's name, class, address, date of birth, blood group, guardian's name and signature, amount of premium paid, and signatures of the student and institute representative. It notes that a copy of the completed form should be submitted along with the student's admission form.

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zeeshan shaikh
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137 views1 page

Yuva Raksha Insurance Registration Form

This document contains a registration form for a group insurance scheme called "YUVA RAKSHA" for students. The form collects information such as the student's name, class, address, date of birth, blood group, guardian's name and signature, amount of premium paid, and signatures of the student and institute representative. It notes that a copy of the completed form should be submitted along with the student's admission form.

Uploaded by

zeeshan shaikh
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

“YUVA RAKSHA”

(GROUP INSURANCE SCHEME FOR STUDENTS)


STUDENTS REGISTRATION FORM
(Copy to be submitted alongwith the Admission Form)

1. Name of Insured (Student) :- ______________________________________

2. Class :- ______________________________________

3. Residential Address :- ______________________________________

______________________________________

______________________________________

______________________________________

4. Students’ Date of Birth :- ______________________________________

5. Blood Group :- ______________________________________

6. Name of the Guardian :- ______________________________________

7. Signature of the Guardian :- ______________________________________

8. Amount of premium paid :- ______________________________________


In Cash or in Cheque (details)

________________________
Student’s Signature

---------------------------------------------------------------------------------------------------------------------------

FOR OFFICE USE ONLY


Received from student (Name ______________________________________ of

___________________ course ) premium of Rs. ______________________ against the receipt

no. ____________ dated _______________________.

Institute / Department / College Seal / Stamp with Signatures

(College to preserve the slip alongwith Admission Form)

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