PROFORMA (Annexure-I)

HEALTH INSURANCE POLICY FOR SINDH SCRETARIAT EMPLOYEES

AND THEIR ENTITLED FAMILY MEMBERS
1. Plan (A/B/C)*
2. Personal No. of Employee* *
3. Name:
4. Father/Husband Name:
5. Gender:
6. Designation:
7. BPS/Grade:
8. Name of Department/present Positing:
9. D.O.B (Age as on 31st Dec. 2016).
10. CNIC No.
11. Marital Status:
12. Date of Appointment
13. Department/Office (Sectt. Side)
14. Date of Retirement:
15. Cadre/Service :
16. CONTACT:
(a) Phone(Home)
(b) Phone(Office)
(c) Mobile
(d) E-mail:
17. NO. OF DEPENDENTS
(a) Spouse (s):
(b) Parents:
(c) Children:
18. Address: (Home)
19. Address: (Office)
DEPENDENTS INFORMATION
Relation
Sr Father’s Age on 31st CNIC/ B-Form
Name of Dependent (s) Gender D.O.B with
No. Name Dec. 2016 (Nadra)***
Employee
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

UNDERTAKING/CERTIFICATE
It is certified that the information given above is correct and that the employee
namely mr./Mrs./Ms.
S/O/D/o , bearing Personnel ID No. is a regular
Sindh Secretariat Employee or is an Officer/Official currently posted at the Sindh Secretatriat,
Karachi. He /She Was appointed as (BPS - ) in
Department (Sectt. Side) and is currently serving
in department againt the post of
(BPS- ) since date and is drawing his/her
salary from (DDO Code) of Department. It is also
confirmed that he /she is neither working on contract/ad-hoic/daily-wages/conterminous basis nor he
/ she is an appointee of any Authority, Autonomous/Semi-Autonomous Body, Project/Program etc.

Signature of the Employee Name, Signature & Stamp of Section Officer/DDOP

Designation: Department

* Plan-A BPS-19-22 Plan-B: BPS-16-18, & Plan-C: BPS-01-15.

** A Certified copy of pay slip issued by the accountant General, Sindh Must be attached herewith.
*** A Copy of CNIC/B-form/FRC Issued by NADRA, Duly attested must be attached herewith.
Note:- All columns shall be filled in duly and no column should be left blank, the incomplete Proforma
shall not be entertained. The Proforma shall necessarily be submitted through proper Channel.