PRADHAN MANTRI SURAKSHA BIMA YOJANA CLAIM FORM

PRADHAN MANTRI SURAKSHA BIMA YOJANA CLAIM FORM 

This form is issued without admission of liability and must be completed and returned within 7 days after its receipt. 

Claim No._____________________ 

Policy No.__________________________________ 

1. Name in Full__________________________________ Address______________________________________ ______________________________________ 

Contact Number_______________________________ 

2 2. Name of the Bank with address_____________________ ______________________________________________ ______________________________________________ 

Saving Account No._______________________________ 

3. A) When did the accident / death occur? State Day, Date and Hour 

B) B) Where did it occur? 

C) Give full particulars of the cause of death / injuries sustained. 

B) 4. Give name and address of the attending Doctors 

5. State where and when a Medical or other Officer of the Company can visit you, if necessary. 

6. A) In case of Death, Original FIR / Post Mortem Report/ Death Certificate to be attached. 

B) In case of Disability, Disability Certificate from Civil Surgeon to be attached. 

I HEREBY 

DECLARE and warrant the truth of the foregoing particulars in every respect, and I agree that if I have made, or if shall make false or untrue statement, suppression or concealment, my right to compensation shall be absolutely forfeited. 

Dated _______________________ 

Signature_______________________________________ 

(Claimant)

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