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Please tick any one box in each row:
Farmers' Gender: M F
Farmers' Category: SC ST OBC Others / General

Details oI individual Iarmers enclosed Yes No Branch wise details enclosed Yes No
1. Under the provisions oI the National Agricultural Insurance Scheme (NAIS), we hereby declare the aggregate amount oI SUM INSURED, Ior
the proposals received in the month oI .............................(by branches / PACB' under the jurisdiction oI our OIIice) as per the schedule below.
We also declare that additional sums insured, above the normal coverage limits, iI any, are as per the option exercised by the Iarmers through
proposal Iorms.
2. It is certiIied 1) that all proposals submitted to the bank branches / PACB under our jurisdication are covered, ii) that all guidelines with regard to
NAIS issued by the SLCCCI Irom time to time have beenIollowed.
Date oI.......................................................
Name oI the Signatory: Designation: Authorised Signatory oI Nodal Bank:

Declaration No. (To be allotted by Bank) NODAL BANK CODE:

State Season:Year
District Name NotiIied Block Crop Name
NotiIied FIRKA(iI applicable)
Part A: Normal coverage upto the amount of value of threshold yield. Premium Rate
Category of Farmers No of Area Insured Sum Insured i.e Full Net
Farmers in (Hectares) 100of Loan Premium Subsidy Premium
1. Small / Marginal Farmers
2. Other Farmers
Part B: Additional coverage over Part A up to the value of 150 of average yield. Premium Rate
Category of Farmers No of Sum Insured above value of threshold Full Net
Farmers yield and upto the value of Premium Subsidy Premium
150 of average yield
1. Small Marginal Farmers
2. Other Farmers
DD No.: DD Date: DDAmount:
Note: 1. All Code Boxes shall be Iilled up by AIC. 2. Guidelines Ior Iilling up declarations overleaI
From [Noda| ank) Address & Phone No.

Agriculture Insurance Company of India Ltd.

Reg|ora| 0ll|ce Crerra|: [Tar|| Nadu, Pord|crerry, Ardarar ard N|cooar ls|ards)
NeW No.323, [0|d No.15), 1s| F|oor, Ardrra lrsurarce 3u||d|rg,
Trarou Cre||y 3|ree|, Parrys Correr, Crerra| - 00 001. Te|: 011 - 1310 3100 - 311
Te|elax: 011 - 1310 3118 To|| Free No: 1800-103-55
e-ra||: ro.crerra|_a|col|rd|a.cor Weos||e: WWW.a|col|rd|a.cor
1. This Declaration Iormat should be used only Ior NON-LOANEE Iarmers and Separate Declaration must be Iilled in Ior each crop and
each notiIied area.
2. Only one copy oI the Declaration must be submitted to AIC, Chennai Regional Office and well beIore the prescribed cut-oII date (a
copy may be retainedby the bankIor their record).
3. Complete address oI Nodal Bank along with the telephone number must be given to Iacilitate Iurther communication, whenever
4. Code particulars (boxes) shall be Iilled up by AIC.
5. Care should be taken to declare all proposals received by the bank branches / PACB as per the cut-oII dates. There should be strict
compliance oI all stipulations/ guidelines oI the Scheme and the notiIication by the SLCCCI.
6. The Proposals received during the month shall be declared to AICCrop Cell by the end oI next month. Kindly ensure that there is no
duplication incoverage oI any Iarmer either by the same bank or vis-a-vis other banks.
7. Whenever any clarifications in respect of Declarations submitted by bank is sought for by theAICState Level Cell, the same
must be submitted within one month of AICletter and no clarification will be entertained by AICthereafter for any purpose
whatsoeverincludingreopening of claims.
8. SpeciIic guidelines Ior Iillinginthe Schedule:
(a) Care should be taken to speciIy the Correct NOTIFIED AREA, MONTH OF LOANING as also CROP in each Declaration.
Claims Iollowing anychanges / Corrections innotiIied area/crop will not be entertained by AIC.
(b) Sum insured to be covered under NAIS must be declared separately Ior "Small / Marginal Farmers" and "Other Farmers". In order to
get the insured sum separately declared upto value oI thershold yield, and beyond (which attracts acturial premium) separate sub-
sections are made in the schedule. These sub-sections are as Iollows:
Part-A: Normal coverage uptothe value oI threshold yield.
Part-B: Additional coverage beyond value oI threshould yield and upto the value oI 150 oI average yield.
For Food Crop & Oilseeds, the premium rates applicable Ior Part Awill be lowest oI Ilat rates oI actuarial rate and in case oI Part-B. it
will be actuarial rate. For annual commercial / horticultural crops, all sup-sections. viz., Part-A&B will attract actuarial premium
rate. The applicable premium rates Ior various crops under various sub-sections shall be obtained Irom notiIication details Ior the
Anon-loanee Iarmer who as per scale oI Iinance may have become eligible Ior loan oI Rs.20,000 Ior his Groundnut crop on 4 hectares
(iI he had availed loan) want to avail sum insured beyond value oI threshold yield. The value oI threshold yield on 4 hectares is say,
Rs.24,000 and that oI 150 oI average yield is say, Rs.45,000. The Iarmer, iI he decides to go Ior sum insured beyond the value oI
threshold yield, can choose any amount between Rs.24,000 and Rs.45,000. II the Ilat premium rate is 3.5 and actuarial rate is 8.0
and assuming that the Iarmer has chosen a sum insured oI Rs.35,000, then the Iarmer will Iigure in part-AoI schedule to the extent oI
Rs.24,000 and in part-B oI schedule to the extent oI Rs.11,000 and pays premium 3.5 on Part-A and 8.0 on Part-B. The
Iarmer's acreage having been noted in part-AoI schedule, is not required to Iigure in Part-B oI schedule, while all other relevant
particulars shall Iighre inall 2 parts oI schedule.
(c) Full premium column is to be computed by multiplying sum insured with premium rate. Subsidy in premium in respect oI S/M
Iarmers is 50 oI Iull premium. Premium remitted is Iull premium less subsidy. Amount remitted under the particular declaration
must be the diIIerence inthe grandtotal between the Iull premium and the subsidy.
(d) The bank branches / PACBshall process andveriIy the land possession documents Ior all the proposals.
9) Bank Service Charges at the rate oI 2.5 will be allowed to the lending branches / PACBs. on collection oI premium and will be
settled through Nodel Banks at the close oI the season.
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Lamee, Oeeee - 600 001. 044 - 43404300 to 3416 Fax: 044 - 43403418
Toll Free No.1800-103-6565 e-mail: website:
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