ANNEXURE-I

"SBI Health Assist" Scheme

GROUP MEDICLAIM POLICY `B' FOR SBI RETIREES

APPLICATION FORM FOR Policy 'B': 16.01.2024-15.01.2025

Date of Payment of Premium Jan 5, 2024

Journal No. 236395336
Amount paid 26,679

Chief Manager
State Bank of India,
Branch / Administrative office,
AO CHENNAI SOUTH

Dear Sir,

SUB: Family Floater Group Health Insurance Policy `B' for SBI Retirees
Policy Period 16.01.2024-15.01.2025

I am interested in joining the Family Floater Group Health Insurance Policy of State Bank of India
(Policy B - SBI Health Assist Scheme) and furnish the required information as under:

SI. Particulars Remarks

1 P.F Index No. 1459465

2 Name of retiree / Family pensioner SRINIVASA DESIKAN S

3 Date of birth of retiree / family pensioner Aug 15, 1947

Age of retire / Family pensioner in year

4 76
(completed age as on January 2022)
5 Date of joining the Bank

6 Date of Retirement Aug 31, 2007

Date of Death of deceased employee /

7
pensioner (applicable for family pensioner)

8 Retried as Deputy Manager

PHA00000000000000141499 PF Index: 1459465 Page 1 of 5

9 Age (in years) as on the date of retirement 60
10 Gender Male
Type (please write Pensioner / Family
11 Pensioner
pensioner / Retiree )
12 Category Existing members of SBI Health care / Policy-A.
Whether dismissed or terminated from
13 No
service
Whether Rule 19(3) was invoked on
attaining the age of retirement
14 (If yes,please furnish the details of the No
disciplinary case, date of its conclusion
and penalty, if any imposed )
62,6THSTREET,
BHUVANESWARINAGAR,SELAIYURPO
Address ST, EASTTAMBARAM,CHENNAI,
Tamilnadu, India - 600073
15 City / District EASTTAMBARAM,CHENNAI
Address for Communication
State Tamilnadu

Pin Code 600073

62,6THSTREET,
Address BHUVANESWARINAGAR
Madambakkam Chennai 600126,,
16 Address for Delivery of Insurance Card etc. City / District CHENNAI,CHENGALPATTU
State TAMIL NADU,India
Pin Code 600126

17 Landline No. (with STD code)

Mobile No. (it will be used for
18 8015674795
registration under E-pharmacy scheme)
19 Alternate Mobile No. 9486847795
20 Email ID VIMALADESIKAN@GMAIL.COM
21 Correspondance Email ID
22 Name of Spouse(if any) VIMALA S
23 Date of Birth of Spouse Jun 2, 1949

24 Age of spouse in year 074

PHA00000000000000141499 PF Index: 1459465 Page 2 of 5

 Name of the Date of
Name of disabled Child / Childrens (if any) SI disabled child Birth
Gender Age
(Attach valid disability certificate issued by 1. 000
25
medical officer not below the rank of Civil
2. 000
Surgeon)

Name of Pension/ Family pension paying Name of the Branch Branch Code No.
26
branch Selaiyur 07948

27 Pension Account No. (11 digit) 10241991138

28 IFSC Code SBIN0007948

29 E-Pharama URLIFE
BASIC COVER PLANS
Gross Premium (A)
Sum Insured Basic Premium GST @ 18%
Rounded off
30
300,000 17,343 3,121.74 20,465

ADDITIONAL SUPER TOP-UP COVER**

Sum Insured of Gross Premium
Base plan Additional Super top- Basic Premium GST @ 18% (B)
31 up Rounded off
300,000 1,100,000 5,266 947.88 6,214

CRITICAL ILLNESS COVER**

Gross Premium (C)

Sum Insured Basic Premium GST @18%
Rounded off
32
0 0 0 0

** Critical Illness Cover and Additional Super top-up cover will not be available separately and
can be taken only with a Base Plan.

** Critical illness cover is not available for retirees with age above 65 years

N.B. : Pro-rata premium for new retirees will be applicable in all the plans i.e. Basic Cover
Plans Additional super top up and Critical Illness Plans.

Employees retiring during currency of the policy should apply by paying the pro-rata
premium within 90 days from next day of their date of retirement.

SUPER TOP-UP COVER (TO BE PAID BY BANK)

33 Gross Premium(D)
Sum Insured Basic Premium GST @18%
Rounded off

600,000 6,951 1,251.18 8,202

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 CALCULATION OF TOTAL PREMIUM (with GST)

Premium for Premium for Premium for

Premium for Additional Super Critical Illness Super top-up Total Premium
Base Plan top-up Plan (if any) (if any) Paid (with GST)
34

(A) (B) (C) (D) A+B+C+D

20,465 6,214 0 8,202 34,881

35. Declaration of Nominee/s :

I, Mr./Mrs./Ms. SRINIVASA DESIKAN S , a pensioner of the Bank/ a retired employee / spouse of

the de ceased employee do hereby assign the money payable by “SBI General Insurance Co.
Ltd.” in case of my death to Mr. / Mrs. / Ms. VIMALA S Relation P and further declare that his/her
receipt shall be sufficient discharge of the company.

36. Debit Authority :

I am aware that I along with my spouse and disabled child/children (if any) will be eligible for a health
insurance cover under the Family Floater Group Health Insurance `Health Assist'. I hereby authorize
the Bank to debit the insurance premium amount of Rs. 26,679 to my pension / family pension
account No. 10241991138

I undertake to keep sufficient balance in my above account for debiting insurance premium for the
policy year 2024-2025 failing which the policy may not be issued to me. I am also aware that Bank
may at its sole discretion can modify the terms and conditions of the policy from time to time.

37. Consent-cum-undertaking:

I am desirous of availing the “SBI Health Assist” Scheme (“Services”) offered by the Bank through
third-party agencies/service providers/vendors (“Third Party Entities”). The Bank may also at its sole
discretion offer certain additional services, (information regarding such service/s will be Circulated
subsequently by Bank) (“Additional Services”) through Third Party Entities selected by the Bank. For
the purpose of rendering Services and/or Additional Services, I do hereby expressly authorize the
Bank to share, disclose or exchange my PF ID/ contact details and details of my/ my family members
to Third Party Entities.

I understand that availing of Additional Services will be on voluntary and chargeable basis. I
undertake that I will use aforesaid additional services for my genuine personal purpose and for the
declared family members only. In case of any misuse of the facility is reported and/or the facility is
used for commercial purposes, Bank/ Third Party Entities are free to take appropriate measures
including to suspend the services if so warranted.

PHA00000000000000141499 PF Index: 1459465 Page 4 of 5

Also, I undertake that any liability, damage, claim, loss etc. that the Bank may suffer or incur, on
account of any acts of omission on my part in connection with the use of Additional Services, shall be
recoverable from me on first demand made by the Bank.

I understand that the Additional Services are provided by Third Party Entities and any issues/
concerns related thereto need to be taken up with Third Party Entities only. The Bank shall not be
responsible for any loss incurred by me on account of use of such Additional Services provided by
Third Party Entities.

I have read, understood and accept the contents of this `Consent-cum-Undertaking'.

Place :

___________________________________
Date : Jan 5, 2024
Signature of retired Employee / Spouse

For office use only

Certified that Shri / Smt. _____________________________ is a retired employee / spouse of the

retired / deceased employee of SBI / e-ABs and he / she has remitted the insurance premium as per
the following details:

Transcation No. (Journal No.): Date : Amount :

236395336 Jan 5, 2024 26,679

PHA00000000000000141499 PF Index: 1459465 Page 5 of 5