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I hereby give my unconditional consent to join the Group Personal Accident Insurance Scheme of United India Insurance Co. Ltd. The details of the scheme have been explained to me and I understand that the premium payable is Rs.50/- (Rupees Fifty only) for one year, inclusive of Service Tax, for the sum assured of Rs.5.00 lakhs. The personal details are appended.

Name of the insured Sex Age & Date of birth SB A/c. No. and Branch office Sum Insured Name and address of the Nominee, in case of death Details of the guardian, if the nominee is a minor Male /Female

Rs. 5,00,000/- (Rupees Five lakhs only)

I hereby authorise State Bank of Travancore, Branch to deduct the Insurance premium of Rs.50/- (Rupees Fifty only) payable towards the `SBT- UNI SURAKSHA Personal Accident Insurance Policy from my SB Account No. This authority is irrevocable. I agree that in case I close my account with State Bank of Travancore, I will cease to be a member of this Group Personal Accident Insurance Scheme. I understand that no liability and / or risks relating to this Group Personal Accident Insurance Scheme shall get devolved on the Bank. All claims on account of accidental death / disability will be settled by United India Insurance Co. Ltd. My nominee / legal heirs shall lodge the claim with United India Insurance Co. Ltd., through your branch, along with the Claim forms and all other relevant documents. I authorise you to collect the claim amount on my behalf / on behalf of my nominee / legal heirs and credit the same to my account / the account of my nominee / legal heirs, as the case may be, after recovering any outstanding amounts due from me to State Bank of Travancore under any loans / credit facilities availed by me. I understand that if I have more than one Savings Bank account with the Bank and if more than one Personal accident cover is taken under this scheme, only the first insurance shall be a valid one and all the remaining insurances shall be deemed as null and void. I also understand that in case of a claim, the premia collected in respect of the invalid policies will not be refunded under any circumstance. I also understand that the cover for the risks under the scheme shall commence from the day following the date of debit of the premium to my above mentioned savings bank account. Place : Trivandrum Date : Signature of insured person.

Debited premium of Rs.50/- (Rupees Fifty only) on .. to the Savings Bank account number indicate above and credited to the United India Insurance Co. Ltd. Date : Branch Manager / Authorised Official State Bank of Travancore .Branch.