ae aah Ufaer H YRan & fey TEN Consent-cum-Declaration Form Tobe iledn by members joining the scheme during the Enrolment ‘gency BC Code ‘Savings Bank Account No, ‘Date of Entry into the Scheme : 1 June / July / August / September, 2015 1. Ware a Full "Mobile Conia Number 6. aha No, avaiable 1 Dae of Binh (As perKYC document) (mm) 7. Whether sifering rom any disability yes, dtl threo ¢ Email 1 Name & Adress ofthe Nominee, any, and Relationship wih him her, Name & Adres of Guardian, nominee is mor | hereby give my consent to become a member of‘ Pradhan Mant Suaksha Bima Yojana’ which will be administered by the above Bank as Master Pothole. ‘hereby authorie you to debit today my Saving Bank Account wth your Branch wth Rs 12 (Rupees Twelve ony) pls Service Tax, applicable and on or before 31" May every subsequent year unl further instructions to the contrary (strikeout whichever is not applicable) a sum of Rupes Twelve ora revised amount that may be decided wit immediate intimation ome. | hereby nominate my nominee a indicated abore forthe benefits under the scheme, in the event of my death, Inthe event of my death before the nominee teaching the ageof 18 years, hereby appoint the egal guardian ofthe nominee a indicated above for the purpose of receiving the benfits under the scheme. ‘declare that am not insured under Pradhan Mati Suraksha Bim Yojana under any other Savings Bank Account. Incase the same is found to eit premium shall tad forfieted and no claims would be pad. ‘agree tha the cover shallcommence fromthe tcf the month subsequent to the date of enoimentin he scheme, |agre o pay fll annual premium even join the Scheme afer the commencement ofthe Master Policy | agre tat my membership in the Scheme wil remain in force as ong as all premiums due are paid and unt! have atid age 70 years as on Annual Renewal Date, {agree to abide by the terms and conditions ofthe above Scheme. agree to your conveying my personal dels, require, regarding my admission into the Pradhan Mant uraksha Bina Yojnato (Name of he Insurance Company, tobe preprinted) "hereby deciare that the above statements are tre in all respects and that | agre and declare that the above information shall form the basis of admission to the above Scheme and tha any information be found unrue, my membership to the Scheme shall be treated as canceled. Date ‘Signature ofthe Account older Signature verted (Bank Branch Oficial) ACKNOWLEDGEMENT CUM CERTIFICATE OF INSURANCE ‘We hereby acknowledge receipt of “Consen-cum-Delaration For” from Shr Smt holding Saving Bank ‘count No. » Aadhat No, (f avaiable) consenting and authoring aodebit from the specified Savings Bank Account to jin’ the Pradhan Marti Suraksha Bima Yojana with (Name ofthe Insurance Company) under Master Policy No, ‘eying coverage as per the Scheme, subject to comectnes of infomation provided rearing eligiity and receipt of consideration aunt. Seal & Signature of Authorised Bank Official pra a Sri ay od ot sora fw erent F an te fra & ora rT wears