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Aappas Habule

1. This document is a consent form for an individual named Aappas Mahadev Habule to enroll in the Pradhan Mantri Suraksha Bima Yojana insurance scheme. 2. It provides his personal details like name, address, date of birth, bank account and contact information. 3. By signing, he authorizes an annual auto-debit of premium from his savings bank account, appoints a nominee in the event of his death, and agrees to the terms and conditions of the insurance scheme.

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Deshmukh Virat
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45 views

Aappas Habule

1. This document is a consent form for an individual named Aappas Mahadev Habule to enroll in the Pradhan Mantri Suraksha Bima Yojana insurance scheme. 2. It provides his personal details like name, address, date of birth, bank account and contact information. 3. By signing, he authorizes an annual auto-debit of premium from his savings bank account, appoints a nominee in the event of his death, and agrees to the terms and conditions of the insurance scheme.

Uploaded by

Deshmukh Virat
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PRADHAN MANTRI SURAKSHA BIMA YOJANA

Consent-cum-Declaration Form
(To be filled in by members joining the scheme during the permitted "Enrollment Period")

Agency / BC Code: 100225492

Savings Bank Account No: 40630241248

Date of Entry into the Scheme : 01/01/2022

Bank Reference Number :

5. Whether suffering from any


1. Name in Full : AAPPAS MAHADEV HABULE disability :N
If yes, details thereof :
6. Name of the Nominee, if any :
2. Address : AT POST- YEOTI DIST-OSMANABAD VILLAGE: YEWATI, DISTRICT:OSMANABAD, CITY: AAPPAS HABULE
KARMALA,STATE:MAHARASHTRA, PIN:413603 Relationship with the Nominee : WIFE
DOB of the Nominee :01/01/1992
7. Aadhaar No, if
3. Date of Birth(As per KYC document):01/01/1985
available :830363375545
4. Email ID :
8. Address of the Nominee :NA
Mobile /Contact Number :9518355099
Name of Guardian, if nominee is minor :

I hereby authorize you to debit today my Saving Bank Account with your Bank with Rs.12/- (Rupees Twelve only) plus Service Tax,
if applicable, and on or before 31st May every subsequent year until further instructions to the contrary (strike out whichever is not
applicable) a sum of Rupees Twelve or a revised amount that may be decided with immediate intimation to me. I hereby nominate
my nominee as indicated above for the benefits under the scheme, in the event of my death. In the event of my death before the
nominee reaching the age of 18 years, I hereby appoint the legal guardian of the nominee as indicated above for the purpose of
receiving the benfits under the scheme.
I declare that I am not insured under Pradhan Mantri Suraksha Bima Yojana under any other Savings Bank Account. In case the
same is found to exist, premium shall stand forefieted and no claims would be paid.
I agree that the cover shall commence from the 1st of the month subsequent to the date of enrolment in the scheme.
I agree to pay full annual premium even if I join the Scheme after the commencement of the Master Policy.
I agree that my membership in the Scheme will remain in force as long as all premiums due are paid and until I have attained age
70 years as on Annual Renewal Date.
I agree to abide by the terms and conditions of the above Scheme. I agree to your conveying my personal details, as required,
regarding my admission into the Pradhan Mantri Suraksha Bima Yojana to National Insurance Company Ltd .
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.

Dated: 16/12/2021

Signature verified
Signature of the Account Holder
(Bank Branch Official)

ACKNOWLEDGEMENT CUM CERTIFICATE OF INSURANCE

We hereby acknowledge receipt of "Consent-cum-Declaration Form" from Shri / Smt. AAPPAS MAHADEV HABULE. holding Saving Bank
Account No.40630241248, Aadhaar No. : 830363375545 consenting and authorizing auto-debit from the specified Savings Bank
Account to join the Pradhan Mantri Suraksha Bima Yojana with National Insurance Company Ltd under Master Policy
No24060042158200000061 certifying coverage as per the Scheme, subject to correctness of information provided regarding eligibility
and receipt of consideration amount
Customer CIF :90870161444
Bank Reference Number :
Date of Entry into the Scheme : 01/01/2022
Seal & Signature
Authorised Bank Official

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