Nomination form-6 MGEGIS he has no family

I                                                                                        having no family hereby nominate the person/persons mentioned below and confer on him/them the right to receive to the extent specified below any amount that may be sanctioned by the State Government under State Government Employees Group Insurance Scheme, 1992, in the event of my death while in service or which having become payable on my attaining the age of superannuation may remain unpaid at my death

Name & Address(es) of nominee/nominees

Relationship

With Govt.

Servant

Age

*Share of amount

to be Paid to each*

Contingencies

on the happening of which the nomination shall become

Invalid**

Name, address &

relationship of the

person, if any, to

whom the right of

the nominee shall

pass in the event of

His/her predeceas-

ing the Govt.

service

1

2

3

4

5

6

Dated this

day of

200

at

Signature of the subscriber:

Name in Block letters:

Designation:

Two witnesses to signature

Signature:  

Signature:

Name:

Name:

Address:

Address:

N.B.: The Government Servant should draw line across the blank space below his last entry to prevent the insertion of any name after he has signed.

* This column should be filled in so as to cover the whole amount may be payable under the Insurance Scheme.

** Where a Government Servant who has no family makes a nomination, he shall specify in this column that the nomination shall become invalid in the event of his subsequently acquired a family.