POST SUPERANNUATION MEDICAL BENEFIT SCHEME-BDL

REQUEST FOR RENEWAL

POLICY PERIOD 2022-2023

SCHEME - Select a value -PSMB1PSMB2PSMB3

Staff Number

Name

Address

State

Email

Primary Beneficiary - Select a value -Ex-EmployeeSpouse

(To be indicated separately in respect of the Ex-Employee / Spouse)

NAME OF THE PRIMARY BENEFICIARY

Enter the name of the Primary Beneficiary

Relationship - Select a value -SelfSpouse

(Indicate Self/ Spouse)

Present Status of Primary Beneficiary - Select a value -SurvivingExpired

DATE OF DEMISE

Date

Secondary Beneficiary - Select a value -Ex-EmployeeSpouse

(To be indicated separately in respect of the Ex-Employee / Spouse)

NAME OF THE SECONDARY BENEFICIARY

Enter the beneficiary name

Relationship with Secondary Beneficiary - Select a value -SelfSpouse

(Indicate Self/ Spouse)

Present Status of Secondary Beneficiary - Select a value -SurvivingExpired

Date of Demise (if expired)

Date

What code is in the image?

Enter the characters shown in the image.