Declaration

THE MERCHANT NAVY OFFICERS' WELFARE FUND (MNOWF)
Udyog Bhavan, 4th Floor, 29, Walchand Hirachand Marg, Ballard Estate, Mumbai 400 001.

8828326202 Tel.: 022-49680968 E-mail : mail@mnowf.com Web : www.mnowf.com
(PARTICULAR OF OFFICER AND FAMILY - WIFE, TWO CHILDREN UNDER 25 YEARS)

Officer's Full Name * :

Rank * :

Employee Code No * :

Name of INSA Memberline Company Employed With * :

Date of Appoiment in present Company * :

Mobile No * :

Email ID * :

Particular of the Service during the last four years * :

Permanent Residential Address * :

Tele No with STD. Code * :

Fax No with STD. Code * :

Name of the Doctor His Qualification And Complete Address * :

Are you, your wife and / or children covered with any Insurance Company under any medical Scehme ? If so, name the Comapany(ies) type / ss of Scehme's and amount of coverage * :

Is your wife gainfully employed ? If so , give particular of her employement * :

For Office Use Only :

RECEIVED ON:

Inward No:

BY:

Particular of Offer and Family Member

Sr No. Name In Full Date of Birth (DD/MM/YY)

1

2

3

4

I hereby state that I have Received the copy of the Medical Brochure and Claims Forms :

I undertake to refund / make good the loss in respect of payment made to me with respect to claims in the events of the above information being found to be untrue / incorrect :

Place * :

Date * :

Name Of

  Officer

  Wife :

Signature

  Officer

  Wife :

MUI * :

DECLARATION FORM

(To be Filled By Officer)