GROUP INSURANCE SCHEME FORM GIS – A (Vide Rule 5)

To The ......................................................................... ................................................................................. ................................................................................. (DDO/Controlling Officer) Sir/Madam, I, .................................................................................................................................... (Name), ....................................................................................................................... (Designation) belong to* ................................................................................ on the scale of pay `...................................... working in ...............................................................................................................Department. I request that I may be enrolled as a member of Group .............. (A/B/C/D) having a monthly subscription of ` ................ in the Group Insurance Scheme introduced by the Government as per G.O.(P) 392/84/Fin. dated 9.8.1984. I agree to abide by all the rules and instructions made or to be made by Government relating to the scheme.

Yours faithfully, Place : ...................................................... Date : ......./......./20......... (Name & Signature) *State whether regular establishment, work-charged establishment, contingent establishment, full-time teaching and non-teaching staff or Private School, Private College under direct payment scheme.

For Office use only Entered in Register of Members in Form No.GIS-8 and page one of the Service Book.

Head of Office. (Office Seal)

group insurance scheme - Insurance Departmentsites.google.com/site/alrahiman/gis_form_a.pdf?attredirects=0&d=1%22

request that I may be enrolled as a member of Group .............. (A/B/C/D) ... I agree to abide by all the rules and instructions made ... 20......... (Name & Signature).
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