Raspberry Pi Educational Services - Medical and Term Insurance Enrolment Form

Your Details

Title

First Name

Last Name

Address Line 1

Address Line 2

Address Line 3

Address Line 4

District

Date of Birth

Place of Birth

Mother's Name

Email Address

Phone Number

Height (in centimetres)

Weight (in kilograms)

Any Identification Marks

Employment Details

Profession - Salaried/Business

Industry

Qualification

Office Address Line 1

Office Address Line 2

Office Address Line 3

Office Address Line 4

District

Office Phone Number

Designation

Annual Income

Nominees Information

Name and date of birth of nominees to be added to the scheme:

Nominee 1 First Name

Nominee 1 Last Name

Nominee 1 Date of Birth

Relationship to Nominee

Nominee 2 First Name

Nominee 2 Last Name

Nominee 2 Date of Birth

Relationship to Nominee

Existing Life Insurance & Accidental Insurance Policy Details (Please enter N/A if you do not have any)

Life Insurance Company Name:

Life Insurance Sum Assured:

Accidental Insurance Sum Assured:

Covid

Have you ever been diagnosed with Covid?

YesNo

Have you been hospitalised or treated at home for Covid?

YesNo

If yes, please provide the month and year that you received treatment for Covid:

Documents Required

The following documents are required. Please email all documents to the People and Culture team email address people@raspberrypi.org. Please tick each item that you are able to provide.

If you are unable to provide any of these documents, provide further information in the box below:

Declaration

By submitting this enrolment form I confirm that I would like to join the medical and term insurance schemes.

I confirm

Date

Data processing

I understand that my data will be processed in accordance with the Raspberry Pi Foundation’s privacy policy, which contains information about how my personal data is used.