Annexure 4

AM
N ANTRI JA
A

Union Bank of Indle

PRADHAN MANTRI SURAKSHA BIMA YOJANA

Consent-Cum-Declaration. Form
(To be Fled Iin by members Jolning the scheme during the permitted "Enrolment Period')

Agency/Bc Code

SavingBank Account No
Date ofentryIntothe Scheme: 1" June /July August / September, 2015
1. Name In Full 5. Moblle/ Contact Number_

Address
6. Aadhar No. If available .

3. Dete of Birth ( As per KYC document) ( dd/mmlyyyy) 7. Whether suffering from any disablity .
f yes, detalls there of
and Relationship with him/
8. Name & Address of the Nominee, if any,
4.Email ID
her
9 . Name & Address of Guarding, If nominee is minor.

Suraksha Bima Yojana' wthich will be adminlstered by the above Bank as Master
Thereby glve my consent to become member. of' Pradhan Mantr
a

Pollcy holder.

Account with your Branch 12/-(Rupees Twelve

with Rs. only ) plus GST Tax, If applicable, and
T
hereby authorize you to debit today my Saving Bank is not applicable ) a sum of Rupees
before 31 until further instructtons to the contrary ( strike out whichever
May every subsequent year
on or ora
Twelve revised amount that may be decided with immedlate Intimation to me.

benefits under the scheme, In the event of my death. In the event

of
my death before me
my nominee indicated above for the
Thereby nominate the as
of nominee Indicated above for the purpose of receiving the
age of 18 years, I hereby appoint the legal guardlan the as
nominee reaching
benefts under the scheme.
In the ls found to
I declare that I am not Insured under Pradhan Mantrl Suraksha Bima YoJana under any other Savings Bank Account. case same

exist premium shall stand forefieted and no claims would be pald.

l agree that the cover shall commence from the 1 of the month subsequent to the date of enrolment in the scheme.

lagree to pay full annual premium even ifl join the Scheme after the commencement of the Master Pollcy.

l agree that my membership In the Scheme will remain In force

as long as all premlums due are pald and until Ihave attained age 70 years as on
Annual Renewal Date.

above Scheme. I agree to your conveying my personal detalls,

as requlred, regarding my
agree to ablde by the terms and conditons of the
to The New India Assurance Company Ltd.
admission into the Pradhan Mantri Suraksha Bima Yojana
the above Information shall form the basis of
true in all respects and that I agree and declare that
I hereby declare that the above statemets are
admission to the above Scheme and that if any
Informatlon be found untrue, membershlp to
my the Scheme shall be treated as cancelled.

Date

Signature of the Account Holder

3ignature verifled

Bank Branch Offlclal )

ACKNOWLEDGEMENTCUM CERTIEIGATE OF INSURANCE

holding Saving Bank
of "Consent-cum-Declaration Fom" from Shri/ 8mt.
We hereby acknowledge recelpt consenting and authorizing auto-deblit
Aadhar No. (f avallable).
Account No. Bima Yojana with The New India Assurance Company Ltd. under
Bank Account to Joln the Pradhan Mantri Suraksha
rom the specified Savings Scheme, subject to corectness of Informatlon provided regarding
Aaster Policy No. certifying coverage as
per the
llgibility and receipt of consideration amount.

Seal& Slanature of Authorised Bank Officlal