SBH | fees, ee Sa one State Bank of Hyderabad @ SBI Life VSURANCE Win Us, You're Sure PRADHAN MANTRI JEEVAN JYOTI BIMA YOJANA Consent-cum-Declaration Form {Tobe filed in by members joring the scheme during the permites “Exwalment arog’) For Office Use ‘AgentiBC’s Name" ‘AgencylBC Code No.* Bank Alc deals of AgentiBC —* Signature of Agent/Banking Correspondent™ |,hereby give my consent o become a member of Pradhan Mantr Jeevan Jyot Bima Yojana’ of SBI Life Insurance Corporation Limited which willbe ‘acministeredby your Bankunder MasterPolicy No.76001000539 (obepre-pinted) | hereby authorize you to debit my Savings Bank Account with your Branch with Rs.390/- (Rupees Three Hundred Thity Only) plus Service Tax if applicable towards premium of life cover under PMJUBY.| further authorize you to deduct i future ater 25° May and nl later than on 1" of lune ‘every year unl furher instructions, an amount of Rs:330/- (Rupees three hundred thirty only) and Service Tax if applicable, or any amount as, decided tom mete time, which maybe intimated immediatalyfand when revised, towards renewal of coverage under he scheme. ‘have not authorized any other bank to debit premium in respect of this scheme, |am aware that my ife cover shallbe restricted to Rs.2,00,000!-onlyin the eventofmy death | have ead and understood the Scheme rules and Ihereby give my consenttobecomeamember othe Scheme. | authorize the Sank to convey my personal details, given below, as required, regarding my admission into the group insurance scheme to SBI Life Insurance Corporation Limited, Applicant Details, as per Bank / KYC records Pitre cae: ‘Savings Bank Account No. ‘Aadhar Number, if available Enmailld Mobile No. Name, address and relationship Name and address of Guaraian (any) of nominee (ifrominge is minor) Date of Bith ‘Address | hereby nominate my nominee as above under this scheme, Nominee being minor, his/her uardianis appointed as above, | hereby declare thatthe above statements are true inal espects and that | agree and declare thatthe above information shall form the basis of ‘admission othe above scheme and thatif any information be found untrue, my membership the scheme, shall be treated as canceled Date:__ Signature Adéress: Signature verified (Branch Official) (Rubber Stamp wth bank branch name and code ACKNOWLEDGEMENT SLIP CUM CERTIFICATE OF INSURANCE We hereby acknowledge receipt of “Consent-cum-Declaration Farm’ from Sh / Smt holding Saving Bank Account No. ‘Aadhar No, consenting and authorizing auto-debit from the specified Savings Accountto jin the Pradhan Mantr Jeevan Jyot! Bima Yojana with SBI Life Insurance Corporation Limited for cover under Master Policy No. 76001000539 subject to ‘correctness of information providedregarding eligibility and receipt of consideration amount ‘Seal & Signature of Authorised Bank Official