APPLICATION FOR TOP-UP ARRANGEMENT OF

RUPEES 3.00 LAKHS WITH

UNITED INDIA INSURANCE COMPANY &
ALL INDIA UCOBANK PENSIONERS FEDERATION
The General Secretary
All India UCOBank Pensioners Federation
Kolkata

Date.........................

Dear Sir,
Sub: TOP- UP Group Mediclaim Insurance Policy for the Retired Employees
of UCOBank with United India Insurance Company Limited
PARTICULARS

DETAILS

1. Name of the Applicant: (In Block Letters)

2. Address in Full

3. Phone Number / Mobile Number

4. e mail I D
2. P F Number while in our Bank
3. Date of Retirement from UCOBank
4. Unit to which Member belongs

K A R N ATA K A

5. Policy Number of the Existing IBA Group

Insurance Company for Rs 4.00 Lakhs

H H S 8-

5555555555
H H S 8-

5555555555
6 Details of Cheque: Branch Name
Branch Identification No
Cheque Number
Amount: Rupees
I have read the Terms and Conditions of the TOP-UP Insurance of the United Insurance Company. I am
agreeable to the same and hereby undertake to abide by the conditions mentioned therein.
Place:
Signature of the Member
We confirm that the above Pensioner is a Member of Unit

Signature of the President / Secretary