Medical Insurance Scheme

To Paste
Photograph
The General Manager
Personnel Service
Department(2nd Floor)
UCO BANK
Head Office 2
Sector 1,SaltLake
KOLKATA-700064
Sub:-Application for Medical Insurance
Basic Detail
Renewal Premium Option: Normal Renewal on As Is
Basis(Without Domiciliary cover)
TOP UP OPTION: NO
Full Name (Mr./Ms.): Nila Mukherjee W/O Late
Basudev Mukherjee
EMP NO: 30669
Designation At time of Leaving Peon
Bank:
Mode of Exit: VRS
Date of Birth: 03-03-1964
Date of Leaving the Bank(DD- 03-03-2015
MON-YYYY):
Branch/Office Where Last HEAD OFFICE
Worked:
Gender: FEMALE
Monthly Income: 10000
Account No: 26050110014028
Whether Pensioner: YES
Branch IFSC Code: UCBA0002605
PAN NO: CNBPM2000G
AADHAR NO: 210445155291

Communication Address
House Flat No:24/J Street/Area:BAROYARITALA ROAD
City /District:Kolkata State:West Bengal
PIN :700010 Mobile:9007056453
Land line with STD:null-null email:jyoti.chakraborty@gmail.com

Spouse Detail

Name:null Date of Birth:null

Monthly Income:null Gender:0

DECLARATION : I have gone through and understood the terms of Medical Insurance Scheme as mentioned under provisions of the
10th Bipartite Settlement/Joint Note dated 25/05/2015. I have also read and fully understood the contents of the HO Circulars issued
by UCO Bank from time to time. I am willing to join/renew the said medical insurance scheme, which is extended to the retired
employees subject to payment of agreed insurance premium by me. I also understand and accept that the Bank is in no way responsible
for payment of any amount under the scheme except what is admissible / payable by the insurance company. I authorize UCO Bank to
debit the premium of Rs.24897 and Rs. 0 (for Top-Up) from my pension a/c No.26050110014028 for renewal of insurance scheme for
the period 01.11.2019 to 31.10.2020. I will ensue that sufficient balance is maintained in the account. I fully understand that is case
sufficient balance is not maintained my name will be excluded from the policy. I understand that this option is irrevocable and binding
for further renewal also if not withdrawn in writing.

Signature
Date:16-10-2019