I, Mr./Mrs./Miss--------------------------------------------------------------------------
hereby agree and declare that in the event that Mr./Mrs./Miss------------------------------------------------------------------(Members) becomes physically or Mentally incapable for or in the event that the member default in ,making any payments to the company for the availed service( for any reasons whatsoever )
in accordance with the Member term and conditions. I hereby agree to be his/her nominee and I shall make timely payment of all outstanding dues to the company or to any partner of the company whose services the member has availed.
I shall thereafter be deemed to be the Member and shall comply with the provisions of the member term and conditions issue by the company .I further agree to be bound by the provisions of the Member terms and conditions .I shall sign and execute all documents required by the company to signify my consent to the Member terms and conditions. I further agree that I may be contacted in case of any Medical emergencies and /or the Member has been admitted into a hospital as per the term and conditions of the member terms and conditions and I undertake to extend my full co-operation in such circumstances.
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Signature of the Nominee Name of Nominee:---------------------------------------------------
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