PRADHAN MANTRI JEEVAN JYOTI BIMA YOJANA - CONSENT-CUM-DECLARATION FORM

PRADHAN MANTRI JEEVAN JYOTI BIMA YOJANA

BANK’S NAME LOGO

INSURANCE COMPANY LOGO

 LOGO  OF SCHEME BANK

CONSENT-CUM-DECLARATION FORM

 (To be filled in by members joining the scheme during the permitted ‘Enrollment Period’)

 For Office Use I, hereby give my consent to become a member of ‘Pradhan Mantri Jeevan Jyoti Bima Yojana’ of ------------------ (Name of the Insurance Company) which will be administered by your Bank under Master Policy No. ……………………………… (to be pre-printed) I hereby authorize you to debit my Savings Bank Account with your Branch with Rs.330 (Rupees Three Hundred Thirty Only) plus Service Tax if applicable towards premium of life cover under PMJJBY.

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.330 (Rupees three hundred thirty only) and Service Tax if applicable, 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 to debit premium in respect of this scheme. I am aware that my life cover shall be restricted to Rs.2,00,000 only in the event of my death. 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 the Insurance Company).

Applicant Details, as per Bank / KYC records :

I hereby nominate my nominee as above under this scheme. Nominee being minor, his / her guardian is appointed as above. 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 Address:

Signature verified (Branch Official)

(Rubber Stamp with bank branch name and code)

 Agent’/BC’s Name

* Agency/BC Code No.

* Bank A/c details of Agent/BC –

* Signature of Agent/Banking Correspondent

* Name of the Account holder (as per Bank records)

 Savings Bank Account No. Aadhar Number, if available E-mail Id Mobile No.

Name, address and relationship (if any) of nominee Name and address of Guardian (if nominee is minor)

Date of Birth Address

ACKNOWLEDGEMENT SLIP CUM CERTIFICATE OF INSURANCE

We hereby acknowledge receipt of “Consent-cum-Declaration Form” from Sh / Smt. ………………………………… holding Saving Bank Account No……………………………….. Aadhar No………………………….. consenting and authorizing auto-debit from the specified Savings Account to join the Pradhan Mantri Jeevan Jyoti Bima Yojana with ------------------ (Name of the Insurance Company) for cover under Master Policy No………………………., subject to correctness of information provided regarding eligibility and receipt of consideration amount.

Seal & Signature of Authorised Bank Official ‘

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