PRADHAN MANTRI JEEVAN JYOTI BIMA YOJANA – CLAIM FORM

PRADHAN MANTRI JEEVAN JYOTI BIMA YOJANA – CLAIM FORM

(to be completed by the Claimant & Bank)

1. NAME OF THE SCHEME : Pradhan Mantri Jeevan Jyoti Bima Yojana

2. POLICY NO :                    

3. FULL NAME AND ADDRESS OF THE BANK :  

4. FULL NAME OF THE DECEASED MEMBER :

Insurance Company ID ---- :

 5. DATE OF ENTRY INTO SCHEME BY MEMBER :

6. DATE OF DEATH OF MEMBER :

7. WHETHER DEATH IS DUE TO ACCIDENT : YES / NO, If Yes, submit documentary proof

8. NAME OF NOMINEE * : We hereby declare that the answers to all the above questions are true in every respect. We enclose Death Certificate as the proof of death of the Member.

*In case the Nominee is a minor, the guardian may fill in the claim form. _

____________________________________ 

(Signature of the Nominee* /Claimant)

We hereby certify that the above member was covered under the PMJJBY Scheme and premium was debited from his bank account on the renewal date prior to his death and remitted to ------------------ (Name of the Insurance Company). We also certify that as per our records, Shri/Smt. _____________________ is the nominee of the above insured Member.

PLACE ______________________ ___________________________

DATE: ____________

(Signature of authorized official of the Bank)

Seal

Encl: Death Certificate, Discharge Form and Certificate of Insurance In case of death due to Accident, FIR, PMR, Panchanama also shall be submitted.

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