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Employee Nomination Form

This document is an employee nomination form where an employee can nominate beneficiaries to receive any final settlement amounts in the event of their death. [1] The employee provides their personal details like name, gender, religion, marital status, department and designation. [2] They then nominate up to three beneficiaries along with their name, address, date of birth, age and proportion of settlement amount. [3] Witnesses to the nomination and the employer certify the form.

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Abhinandan Gowda
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705 views

Employee Nomination Form

This document is an employee nomination form where an employee can nominate beneficiaries to receive any final settlement amounts in the event of their death. [1] The employee provides their personal details like name, gender, religion, marital status, department and designation. [2] They then nominate up to three beneficiaries along with their name, address, date of birth, age and proportion of settlement amount. [3] Witnesses to the nomination and the employer certify the form.

Uploaded by

Abhinandan Gowda
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Employee Nomination Form

To,

The Managing & Director & CEO,


Kobelco Construction Equipment India Pvt. Ltd.,
H -200, Sector - 63, Noida Paste your latest
District – Gautam Budh Nagar, passport size photo
Uttar Pradesh - 201307

Dear Sir,

I, Shri/Shrimati/Kumari
(Name in full here)
whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to
receive the full & final settlement amount payable after my death as also the full & final settlement amount to
my credit in the event of my death before that amount has become payable, or having become payable has
not been paid and direct that the said amount of full & final settlement amount shall be paid in proportion
indicated against the name(s) of the nominee(s).
2. I hereby certify that the person(s) mentioned is/are a member(s) of my family.
3. Nomination made herein invalidates my previous nomination.

Nominee(s)
Name in full with full Date of Birth and Age of Proportion by which
address of nominee(s) Relationship with nominee the full & final
the employee settlement will be
shared

S# (1) (2) (3) (4)

1.

2.

3.

4.

Statement
1. Name of employee in full
2. Sex
3. Religion
4. Whether unmarried/married/widow/widower

Page 1 of 2
KCEI-HR-FT-0040 Controlled by QA Controlled Format
5. Department/Branch/Section where employed
6. Designation with Employee/Worker ID, if any
7. Date of appointment
8. Permanent address:
Village Thana Sub-division
Post Office District State

Place:
Signature/Thumb-impression of the
Date: Employee

Declaration by Witnesses

Nomination signed/thumb-impressed before me


Name in full and full address of witnesses. Signature of Witnesses.
1. 1.

2. 2.

Place:
Date:

Certificate by the Employer


Certified that the particulars of the above nomination have been verified and recorded in
Kobelco Construction Equipment India Pvt. Ltd.
Signature of the employer/Officer authorised
Designation
Place:
Date:
Name:
Designation:
Kobelco Construction Equipment India Pvt. Ltd.,
H -200, Sector - 63, Noida
District – Gautam Budh Nagar,
Uttar Pradesh - 201307

Acknowledgement by the Employee


Received the duplicate copy of employee nomination Form filed by me and duly certified by the employer.
Date: Signature of the Employee
(Name:______________________)

Page 2 of 2
KCEI-HR-FT-0040 Controlled by QA Controlled Format

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