PRADHAN MANTRI SURAKSHA BIMA YOJANA
PRADHAN MANTRI
SURAKSHA BIMA
YOJANA
प्रधान मंत्री सुरक्षा
Name of the Branch:
योजना
CONSENT-CUM-DECLARATION FORM
I hereby give my consent to become a member of ‘Pradhan Mantri Suraksha Bima Yojana’ of
………… (Name of Insurer) under Master Policy No. ……………………………… (To be
pre-printed)
I hereby authorize you to debit my Account with your Branch with Rs. 20/- (Rupees Twenty
only), towards premium of accidental insurance cover@ of Rs Two lakhs under PMSBY
(claim payable in case of death or permanent disability# due to accident$). I further authorize
you to deduct in future after 25th May and not later than on 1st of June every year until further
instructions, an amount of Rs.20/- (Rupees twenty only), or any amount as decided from time
to time, which may be intimated immediately if and when revised, towards renewal of
coverage under the scheme.
I have not authorized any other Bank / Post Office to debit premium in respect of this
scheme. I am aware that in case of multiple enrolments for the scheme by me, my insurance
cover will be restricted to Rs. Two lakhs only and the premium paid by me for multiple
enrolments shall be liable to be forfeited.
I have read and understood the Scheme rules and I hereby give my consent to become a
member of the Scheme.
I authorize the Bank to convey my personal details, given below, as required, regarding my
admission into the group insurance scheme to ……….. (Name of Insurer)
Notes:
@ Insurance cover:
Claim of Rs two lakhs payable in case of total disability or death due to accident
Claim of Rs one lakh payable in case of permanent partial disability
$ Permanent Disability means any of the following:
• Permanent total disability-Total and irrecoverable loss of both eyes or loss of use of
both hands or feet or loss of sight of one eye and loss of use of one hand or foot
• Permanent partial disability-Total and irrecoverable loss of sight of one eye or loss
of use of one hand or foot
Accident means a sudden, unforeseen and involuntary event caused by external, violent and
visible means.
Risk cover will start from the date of auto-debit of premium from the account of the subscriber.
Name of the account
Father’s / husband’s name**
holder**
Address of the account
Name of City / town / village
holder
Name of District Name of State
Mobile number of account
Pin Code
holder
Bank / Post Office IFSC Code of Bank
Account No.** Branch**
Name of the KYC
*document submitted KYC* Id number
PAN Number, if AADHAAR Number, if
available** available**
Date of birth ** E-mail Id**
Whether suffering from
If yes, details thereof
any disability
Date of Birth of nominee
Name and address of
nominee
Relationship of nominee
with the account holder
Name and address of Relationship of the guardian
Guardian / appointee / appointee with the
(if nominee is minor) nominee
Mobile number of Mobile number of guardian /
nominee appointee
Email id of guardian /
Email id of nominee
appointee
I hereby enclose a copy of my ------------------as proof of my identity (KYC*) and nominate
my nominee as above under this scheme. Nominee being minor, his / her guardian is
appointed as above.
* Either of AADHAAR card or Electoral Photo Identity Card (EPIC) or MGNREGA card or
Driving License or PAN card or Passport
I hereby declare that the above statements are true in all respects and that I agree and declare
that the above information shall form the basis of admission to the above scheme and that if
any information be found untrue, my membership to the scheme shall be treated as cancelled.
Date: ____ Signature
** Confirmed that the applicant’s details and signature have been verified from the records
available with this Bank / Post Office (or KYC document submitted* by the applicant, in case
it is not available with the bank / Post Office).
Signature of the Bank Official
Date:
(Rubber Stamp with Bank Branch Name and Code)
For Office Use
Name of Agent/ Agency/BC Code
Banking No.
Correspondent’s (BC)
Bank A/c details of Signature of
Agent/BC Agent/BC
ACKNOWLEDGEMENT SLIP CUM CERTIFICATE OF INSURANCE
We hereby acknowledge receipt of “Consent-cum-Declaration Form” from Shri / Ms.
………………………………… holding Bank /Post Office Account
No………………………………. consenting and authorizing auto-debit from the specified
Bank /Post Office account to join the Pradhan Mantri Suraksha Bima Yojana with -------------
----- (Name of the Insurer) for cover under Master Policy No………………………., subject
to correctness of information provided regarding eligibility and receipt of consideration
amount.
Signature of Authorised Official of Bank
Date:
Office Seal
