PGEPHIS - MAIN MEMBER

ENROLLMENT FORM
If you need help, or unable to complete this application form or enable to find DDO code
please contact on toll free No.“104” or read instructions on website www.pbhealth.gov.in

Instructions
E (1) Please fill the Form in Capital letters using Blue/Black Ball Point Pen Only. (2) All Fields are to be filled mandatorily.

Main Member Details (Please tick þ applicable field)

Current Status:

(a) Serving Employee ü (b) Pensioner ü (c) Serving All India Service Officer ü
(d) Retired All India Service Officer ü (e) From Deputation ü
(f) Serving Judges of Punjab & Haryana High Court/Other Judicial Officers ü
(g) Retired Judges of Punjab & Haryana High Court/Other Judicial Officers Please paste your unsigned
ü
recent color Photograph
of size 4.5cm x 3.5 cm
(Passport size)
1) Name (In CAPITAL letters)
(Initial not allowed)
*Please don't staple
the Photograph
2) Father/Husband Name
(In CAPITAL letters)
(Initial not allowed)

3) Date of Birth/ Age D D M M Y Y Y Y Y Y

(years)

4) Gender: Male ü Female ü 5) Marital Status ü ü ü ü

Married Unmarried Widow Divorce

6) Mobile Number

7) Aadhar Number
8) Email Id
9) Spouse Name
(In CAPITAL letters)
(Initial not allowed)

10) Whether spouse in Govt. Job: Yes ü No ü

11) Mailing Address

Department/Office Details (Please tick þ applicable field)

1) GPF ü PRAN ü PPO ü CPF ü

No.
2) Name of Department (Where serving or from where retired)

3) Particulars of the Office

where serving or retired

4) Place of Posting/Last
place of posting from
where retired
5) District

6 A) Grade Pay Group A ü Group B ü Group C ü Group D ü

(Please tick þ)
(GP>=5400)
6 B) In case of Pensioner Class I Class II Class III Class IV
ü ü ü ü
(retiree before 01.01.1996)

7) Date of Joining D D M M Y Y Y Y

8) Date of Retirement D D M M Y Y Y Y
 Main Member Bank Account Details

1) Bank Name
(In CAPITAL letters)

2) Branch Address
(In CAPITAL letters)

3) IFSC Code

4) Account Number

Total Numbers of Dependents

AGE SLAB

below 45 yrs (<45 yrs) 45 to 65 yrs (>=45 yrs to <=65 yrs) above 65 yrs (>65 yrs)

No. No. No.

Total Number of Dependents

** Please attach PGEPHIS Dependent Form giving details of the dependants eligible to be covered as per Punjab Medical Attendant Rules.

Undertaking/Declaration of Main Member

I hereby certify that :
1. I am not availing medical re-imbursement from any other source as a dependent.

2. My spouse or any of my dependent family members declared by me in this Enrollment Form are not separately
enrolled as a Main Member/ or dependents of any other Main Member under this Scheme or are not claiming
medical re-imbursement from any other source.

3. The information supplied by me in this Enrollment Form is factually correct, true, complete and accurate in all
respects and no facts/ information have been concealed/ falsified/ misrepresented by me.
4. I also authorize Insurance Company/ TPA to send me SMS Alerts on my Enrollment Status / Pre- authorization
Status/ Claims status/ Scheme related information on my mobile phone number listed by me in this Form.
5. "I have no objection to the UIDAI sharing information provided by me to UIDAI in Aadhaar with agencies in delivery
of welfare services.”

Date : _________ Signature _________________________

Mobile No.
(please repeat mobile Number)

VERIFICATION OF DDO (on the basis of the certification of the main member above.)

Name of the DDO: _________________________________ Designation: _________________________________

DDO Code:

Name of Department:__________________________________

Other:______________________________________________
(Please specify if DDO Code is not available)

Date:____________ (Signature with Seal)