[Company Logo][Company Name]
- Employee Name:
- [Employee Name]
- Employee ID:
- [Employee ID]
- Designation:
- [Designation]
- Date of Joining:
- [Date of Joining]
1. Scope of Nomination
This nomination covers amounts payable by [Company Name] in the event of my death while in service, including unpaid salary, leave encashment, pending reimbursements, performance bonus or incentive due, and any other company benefit not covered by a separate statutory nomination.
2. Nominee Details
| Nominee Name | Relationship | Date of Birth | Address | Share (%) |
|---|
| [Nominee Name] | [Relationship] | [DD/MM/YYYY] | [Address] | [%] |
| [Nominee Name] | [Relationship] | [DD/MM/YYYY] | [Address] | [%] |
| [Nominee Name] | [Relationship] | [DD/MM/YYYY] | [Address] | [%] |
3. Guardian Details (if any nominee is a minor)
| Name of Guardian | |
|---|
| Relationship with Minor | |
|---|
| Address and Mobile Number | |
|---|
4. Declaration
I hereby nominate the person(s) named above to receive the amounts described in Section 1 in the shares stated. This nomination cancels any earlier company-dues nomination made by me. I understand I may change it by submitting a fresh form.
Signature of Employee
[Employee Name]Date:
[Date]Place:
[Work Location]5. Witnesses
Witness 1
Name
Address
Signature
Witness 2
Name
Address
Signature
HR Acknowledgement
Received and recorded on [Date].
Verified by
[HR Name]HR Department,
[Company Name]Date:
[Date]