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    (Logo of PMSBY) Pradhan Mantri Suraksha Bima Yojana Consent-cum-Declaration Form

    Uploaded by

    Abhishek
    1. This document is a consent form for individuals to enroll in the Pradhan Mantri Suraksha Bima Yojana insurance scheme administered by banks and underwritten by an insurance company. 2. It collects basic individual details like name, address, date of birth, bank account and contact information to process enrollment. 3. Upon signing, the individual consents to an annual auto-debit of premium from their bank account and nominates beneficiaries in case of death.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    (Logo of PMSBY) Pradhan Mantri Suraksha Bima Yojana Consent-cum-Declaration Form

    Uploaded by

    Abhishek
    247 views1 page
    1. This document is a consent form for individuals to enroll in the Pradhan Mantri Suraksha Bima Yojana insurance scheme administered by banks and underwritten by an insurance company. 2. It collects basic individual details like name, address, date of birth, bank account and contact information to process enrollment. 3. Upon signing, the individual consents to an annual auto-debit of premium from their bank account and nominates beneficiaries in case of death.

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    Form

    Original Title

    Applicationform (3)

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    1. This document is a consent form for individuals to enroll in the Pradhan Mantri Suraksha Bima Yojana insurance scheme administered by banks and underwritten by an insurance company. 2. It collects basic individual details like name, address, date of birth, bank account and contact information to process enrollment. 3. Upon signing, the individual consents to an annual auto-debit of premium from their bank account and nominates beneficiaries in case of death.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    247 views1 page

    (Logo of PMSBY) Pradhan Mantri Suraksha Bima Yojana Consent-cum-Declaration Form

    Uploaded by

    Abhishek
    1. This document is a consent form for individuals to enroll in the Pradhan Mantri Suraksha Bima Yojana insurance scheme administered by banks and underwritten by an insurance company. 2. It collects basic individual details like name, address, date of birth, bank account and contact information to process enrollment. 3. Upon signing, the individual consents to an annual auto-debit of premium from their bank account and nominates beneficiaries in case of death.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    (LOGO) LOGO

    (Name of the Insurance Company) (Name of the Bank)

    (Logo of PMSBY)

    PRADHAN MANTRI SURAKSHA BIMA YOJANA

    Consent-cum-Declaration Form

    (To be filled in by members joining the scheme during the permitted “Enrolment Period”)

    Agency / BC Code _______________________________

    Savings Bank Account No.

    1. Name in Full 5. Mobile /Contact Number________________________

    2. Address
    _________________________________________________________ 6. Aadhar No, if available______________________________.
    _________________________________________________________
    _________________________________________________________
    _________________________________________________________
    3. Date of Birth ( As per KYC document) (dd/mm/yyyy) 7. Whether suffering from any disability________________________
    If yes, details thereof_______________________________________

    4. Email ID _____________________________________________ 8. Name & Address of the Nominee, if any, and Relationship with him /
    her________________________________________________________
    9. Name & Address of Guardian, if nominee is minor __________________________________________

    I hereby give my consent to become a member of ‘ Pradhan Mantri Suraksha Bima Yojana’ which will be administered by the above Bank as Master
    Policyholder.

    I hereby authorize you to debit today my Saving Bank Account with your Branch with Rs.12/- (Rupees Twelve only) plus Service Tax, if applicable, and on or
    before 31st May every subsequent year until further instructions to the contrary (strike out whichever is not applicable) a sum of Rupees Twelve or a revised
    amount that may be decided with immediate intimation to me.

    I hereby nominate my nominee as indicated above for the benefits under the scheme, in the event of my death. In the event of my death before the nominee
    reaching the age of 18 years, I hereby appoint the legal guardian of the nominee as indicated above for the purpose of receiving the benfits under the scheme.

    I declare that I am not insured under Pradhan Mantri Suraksha Bima Yojana under any other Savings Bank Account. In case the same is found to exist, premium
    shall stand forefieted and no claims would be paid.

    I agree to pay full annual premium even if I join the Scheme after the commencement of the Master Policy.

    I agree that my membership in the Scheme will remain in force as long as all premiums due are paid and until I have attained age 70 years as on Annual
    Renewal Date.

    I agree to abide by the terms and conditions of the above Scheme. I agree to your conveying my personal details, as required, regarding my admission into the
    Pradhan Mantri Suraksha Bima Yojana to ______________________________________(Name of the Insurance Company, to be preprinted).

    I hereby declare that the above statements are true in all respects and that I agree and declare that the above information shall form the basis of admission to
    the above Scheme and that if any information be found untrue, my membership to the Scheme shall be treated as cancelled.

    Date:_______________

    ____________________________
    Signature of the Account Holder
    Signature verified
    (Bank Branch Official)

    ACKNOWLEDGEMENT CUM CERTIFICATE OF INSURANCE

    We hereby acknowledge receipt of “Consent-cum-Declaration Form” from Shri / Smt. _______________________________holding Saving Bank
    Account No.______________________________, Aadhar No. (if available) ___________________________, consenting and authorizing auto-debit
    from the specified Savings Bank Account to join the Pradhan Mantri Suraksha Bima Yojana with
    _______________________________________________(Name of the Insurance Company) under Master Policy No. ___________________________
    certifying coverage as per the Scheme, subject to correctness of information provided regarding eligibility and receipt of consideration amount.

    Seal & Signature of Authorised Bank Official

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