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* 1. Full Name:

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* 2. Gender:

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* 3. Your Date of Birth:

Date

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* 4. Employee Code:

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* 5. Band:

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* 6. Your Date of Joining:

Date

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* 7. According to the Crimson Mediclaim Policy, who would you like to cover under the mediclaim benefit provided by Crimson:

For your reference:
A1 / A2 / B1 / B2 : Self + 2 dependents (Spouse / Kids / Parents*)
C1 / C2 / C3 : Self + 2 dependents (Spouse / Kids / Parents*)
D1 / D2 / D3 : Self + 2 dependents (Spouse / Kids)

* Parents can be covered as dependents only if you have completed 1 year of tenure with Crimson & will be added at the time of Group Policy renewal in June.

For more details, please refer to the mediclaim policy on CrimsonPulse.
Path: HRIS >> Policy and Process details >>Mediclaim Policy

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* 8. Dependent 1:
Name and Relationship with the dependent

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* 9. Dependent 1:
Date of Birth of dependent 1

Date

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* 10. Dependent 2:
Name and Relationship with the dependent

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* 11. Dependent 2:
Date of Birth of dependent 2

Date

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