PRADHAN MANTRI SURAKSHA

BIMA YOJANA
POLICY WORDINGS

UIN: IRDAI/HLT/FGII/GOVT. SCHEME-PMSBY/15/2015-16

ISO No.: FGH/UW/GRP/155/01

Corporate & Registered Office - 6th Floor, Tower 3, Indiabulls Finance Center, Senapati Bapat Marg, Elphinstone Road, Mumbai – 400013,
Maharashtra, Care Lines: - 1800-220-233, 1860-500-3333, 022-67837800 Email: - [email protected] Website:- www.futuregenerali.in
IRDA Regn. No 132, CIN - U66030MH2006PLC165287

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 Customer Information Sheet
(Description is illustrative and not exhaustive)
S.NO TITLE DESCRIPTION REFER TO POLICY
CLAUSE NUMBER
1 Product Name Pradhan Mantri Suraksha Bima Yojana
2 What am I a. Death Due to Accident – Rs. 2 lakhs Section A
covered for: b. 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 hand or
foot – Rs. 2 lakhs
c. Total and irrecoverable loss of sight of one eye or loss of use of
one hand or foot – Rs. 1 lakh
3 What are the a. Service on duty with any armed force Section C
major b. Medical or surgical expenses
exclusions in c. Intentional self injury (including but not limited to the use or
the policy: misuse of any intoxicating drugs or alcohol).
d. Participation in an actual or attempted felony, riot, crime,
misdemeanour or civil commotion.
e. Whilst engaging in Aviation or Ballooning or whilst mounting into,
dismounting from or travelling in any balloon or aircraft other
than as passenger (fare paying or otherwise) in any duly licensed
standard type of aircraft.
f. Participating in motor racing or trial run as a driver, co-driver or
passenger.
g. Pregnancy and childbirth, miscarriage, abortion or complications
arising out of any of these.
h. War, invasion, acts of foreign enemies, hostilities (whether war be
declared or not), civil war, commotion unrest, rebellion,
revolution, insurrection, military or usurped power or confiscation
or nationalization or requisition of or damage or under the order of
any government or public authority.
i. Nuclear energy, radiation.
j. Any pre-existing disablement prior to the inception of the policy.
5 Payout basis Fixed benefit amount would be paid for covers as specified in the
Pradhan Mantri Suraksha Bima Yojana.
7 Renewal 1. The renewal of this Policy will be by mutual consent and as per the Section D. II. 9
Conditions rates, terms and conditions of the Pradhan Mantri Suraksha Bima
Yojana prevalent at the time of renewal. The renewal premium
shall be paid to us on or before the date of expiry of the Policy or
of the subsequent renewal thereof. The policy may be renewed on
annual basis.
2. Renewals will be lifelong and will not be refused or cancellation will
not be invoked by Us except on ground of fraud, moral hazard or
misrepresentation.
8 Cancellation 1. We may cancel this insurance only on ground of fraud, moral Section D. II. 11
hazard or misrepresentation by giving Insured at least 15 days
written notice, and the Company shall refund a pro-rata premium
for the unexpired Policy Period after deducting full premium for
members who have claimed under the policy.
2. If the Insured wishes to cancel this policy Insured should give us
15 days notice in writing. We shall refund the Insured balance
premium after retaining premium as per the short term scale for
the unexpired Policy Period as well as full premium for the
members who have claimed under the policy as shown below:
Policy Period not exceeding % of annual rate
1 month 25%
3 months 40%
6 months 75%
9 months 90%

(LEGAL DISCLAIMER) NOTE: The information must be read in conjunction with the product brochure and policy
document. In case of any conflict between the CIS and the policy document the terms and conditions mentioned
in the policy document shall prevail.

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 Pradhan Mantri Suraksha Bima Yojana

PREAMBLE
Where the insured named in the Scheduled hereto (hereinto called “The insured”) has applied to Future Generali
India Insurance Company Limited (hereinafter called “The Company”) for the insurance hereinafter set forth in
respect of the person(s) as per schedule attached hereto (hereinafter called the insured person(s) and has paid to
Company the premium herein stated for the insurance of the risks hereinafter specified occurring during the
period stated in the Schedule.

The Insured Person(s) is eligible to be covered under this policy from 18 years upto the age of 70 years with
lifelong renewability subject to continuous renewal of the group policy.

This Policy records the agreement between the Company and the Insured and sets out the terms of insurance and
the obligations of each party.

Now this policy witnesseth that subject to the Terms, Provisions, Exclusions, Definitions and Conditions herein
expressed or contained or hereon endorsed that Company will pay the insured person(s) or nominee as herein
after mentioned.

A. SCOPE OF COVER
If the Insured person(s) shall sustain any bodily injury resulting solely and directly from Accident caused by
external, violent and visible means then the company shall pay to the insured person(s) the sum or sums
hereinafter set forth that is to say:
a. If such injury shall within one calendar year of its occurrence be the sole and direct cause of the death of an
insured person(s) the Capital Sum insured stated in (d) Table of Benefits.
b. If such injury shall within one calendar year of its occurrence be the sole and direct cause of the 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, the Capital Sum Insured stated in (d) Table of Benefits.
c. If such injury shall within one calendar year of its occurrence be the sole and direct cause of the total and
irrecoverable loss of sight of one eye or total and irrecoverable loss of use of a hand or foot, fifty percent
(50%) of the Capital Sum insured stated in (d) Table of Benefits.
d. Benefit Table :
Table of Benefits Capital Sum Insured
a. Death Rs. 2 lakhs
b. Total and irrecoverable loss of both eyes or loss of use of both hands or feet or Rs. 2 lakhs
loss of sight of one eye and loss of use of hand or foot
c. Total and irrecoverable loss of sight of one eye or loss of use of one hand or foot Rs. 1 lakh

B. DEFINITIONS
I. Standard Definitions
Accident Accident is a sudden, unforeseen and involuntary event caused by external, visible and
violent means.
Condition Precedent Condition Precedent shall mean a policy term or condition upon which the Insurer's
liability under the policy is conditional upon.
Illness Illness means a sickness or a disease or pathological condition leading to the
impairment of normal physiological function which manifests itself during the Policy
Period and requires medical treatment.
Injury/Accidental Injury means accidental physical bodily harm excluding illness or disease solely and
Bodily Injury directly caused by external, violent and visible and evident means which is verified and
certified by a Medical Practitioner.
Medical Advice Any consultation or advice from a Medical Practitioner including the issue of any
prescription or repeat prescription.
Medical expenses Medical Expenses means those expenses that an Insured Person has necessarily and
actually incurred for medical treatment on account of Illness or Accident on the advice
of a Medical Practitioner, as long as these are no more than would have been payable if
the Insured Person had not been insured and no more than other hospitals or doctors
in the same locality would have charged for the same medical treatment.
Medical Practitioner Medical Practitioner is a person who holds a valid registration from the Medical Council
of any State or Medical Council of India or Council for Indian Medicine or for
Homeopathy set up by the Government of India or a State Government and is thereby
entitled to practice medicine within its jurisdiction; and is acting within the scope and
jurisdiction of his licence. The registered practitioner should not be the insured or close
family members.
Pre-Existing Disease Pre-existing Disease means any condition, ailment, injury or disease:
a) That is/are diagnosed by a physician within 48 months prior to the effective date
of the policy issued by the insurer or its reinstatement.

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 b) For which medical advice or treatment was recommended by, or received from, a
physician within 48 months prior to the effective date of the policy issued by the
insurer or its reinstatement.
Renewal Renewal means the terms on which the contract of insurance can be renewed on
mutual consent with a provision of grace period for treating the renewal continuous for
the purpose of gaining credit for pre-existing diseases, time-bound exclusions and for
all waiting periods.
Surgery Surgery or Surgical Procedure means manual and/ or operative procedure (s) required
for treatment of an illness or injury, correction of deformities and defects, diagnosis
and cure of diseases, relief of suffering or prolongation of life, performed in a hospital
or day care centre by a medical practitioner.
Unproven/ Unproven/ Experimental treatment means the treatment including drug experimental
Experimental therapy which is not based on established medical practice in India.
treatment
II. Specific Definitions
Accidental Death Death due to accident.
Capital Sum Insured The amount stated in the Schedule, which is the maximum amount, we will pay for
claims made by You in one policy period irrespective of the number of claims You make
or the number of years that You have had Personal Accident policy with Us.
Insured The Master policy holder / Bank in whose name the policy has been issued.
Insured Person Insured means the person(s) named as insured in the Schedule who are covered under
this Policy, for whom the Insurance is proposed and the appropriate premium has been
received
Policy The complete documents consisting of the Proposal, Policy wording, Schedule and
Endorsements and attachments if any.
Policy Holder Organization or person (s) stated in the Schedule
Policy Period The period commencing with the start date mentioned in the Schedule till the end date
mentioned in the Schedule
Proposal The application (Proposal) form for insurance cover submitted to Us along with all
information which has enabled Us in considering whether and on what terms to offer
this insurance
Schedule That portion of the Policy which sets out Your personal details, the type of insurance
cover in force, the period and the sum insured. Any Annexure or Endorsement to the
Schedule shall also be a part of the Schedule.

Please Note:
a) Insect and mosquito bites is not included in the scope of definition of Accident.

C. EXCLUSIONS
A. Standard exclusions:
a) Hazardous or Adventure sports: Code- Excl09
Expenses related to any treatment necessitated due to participation as a professional in hazardous or
adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor
racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.

b) Breach of law: Code- Excl10

Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting
to commit a breach of law with criminal intent.

c) Unproven Treatments: Code- Excl16

Expenses related to any unproven treatment, services and supplies for or in connection with any treatment.
Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to
support their effectiveness.

B. Specific Exclusions
The policy does not cover death, injury or disablement resulting from:
d) Service on duty with any Armed Force.
e) Medical expenses or Surgery expenses
f) Intentional self injury (including but not limited to the use or misuse of any intoxicating drugs or alcohol).
g) Accident while under the influence of alcohol or drugs.
h) Participation in an actual or attempted felony, riot, crime, misdemeanour or civil commotion.
i) Whilst engaging in Aviation or Ballooning or whilst mounting into, dismounting from or travelling in any
balloon or aircraft other than as passenger (fare paying or otherwise) in any duly licensed standard type of
aircraft.
j) Participating in motor racing or trial run as a driver, co-driver or passenger.
k) Pregnancy and childbirth, miscarriage, abortion or complications arising out of any of these.

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l) War, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, commotion
unrest, rebellion, revolution, insurrection, military or usurped power or confiscation or nationalization or
requisition of or damage or under the order of any government or public authority.
m) Nuclear energy, radiation.
n) Any pre-existing disablement prior to the inception of the policy.

D. GENERAL TERMS AND CLAUSES

I. Standard terms and Clauses

1. Disclosure to information norm:

The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of
misrepresentation, mis description or non-disclosure of any material fact by the policyholder.
(Explanation: "Material facts" for the purpose of this policy shall mean all relevant information sought by the
company in the proposal form and other connected documents to enable it to take informed decision in the
context of underwriting the risk)

2. Condition Precedent to Admission of Liability

The terms and conditions of the policy must be fulfilled by the insured person for the Company to make any
payment for claim(s) arising under the policy.

3. Complete Discharge
Any payment to the policyholder, insured person or his/ her nominees or his/ her legal representative or
assignee or to the Hospital, as the case may be, for any benefit under the policy shall be a valid discharge
towards payment of claim by the Company to the extent of that amount for the particular claim.

4. Fraud
lf any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration
is made or used in support thereof, or if any fraudulent means or devices are used by the insured person or
anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the
premium paid shall be forfeited.

Any amount already paid against claims made under this policy but which are found fraudulent later shall be
repaid by all recipient(s)/policyholder(s), who has made that particular claim, who shall be jointly and
severally liable for such repayment to the insurer.

For the purpose of this clause, the expression "fraud" means any of the following acts committed by the
insured person or by his agent or the hospital/doctor/any other party acting on behalf of the insured person,
with intent to deceive the insurer or to induce the insurer to issue an insurance policy:
a. the suggestion, as a fact of that which is not true and which the insured person does not believe to be
true;
b. the active concealment of a fact by the insured person having knowledge or belief of the fact;
c. any other act fitted to deceive; and
d. any such act or omission as the law specially declares to be fraudulent

The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of Fraud, if the
insured person / beneficiary can prove that the misstatement was true to the best of his knowledge and there
was no deliberate intention to suppress the fact or that such misstatement of or suppression of material fact
are within the knowledge of the insurer.

5. Nomination
The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of
claims under the policy in the event of death of the policyholder. Any change of nomination shall be
communicated to the company in writing and such change shall be effective only when an endorsement on
the policy is made. ln the event of death of the policyholder, the Company will pay the nominee {as named in
the Policy Schedule/Policy Certificate/Endorsement (if any)} and in case there is no subsisting nominee, to
the legal heirs or legal representatives of the policyholder whose discharge shall be treated as full and final
discharge of its liability under the policy.

6. Redressal of Grievance
In case of any grievance the insured person may contact the company through
Website: https://general.futuregenerali.in/
Toll Free: 1800-220-233 / 1860-500-3333 / 022-67837800
Email: [email protected]
Courier: Grievance Redressal Cell, Future Generali India Insurance Company Ltd.
Lodha I –Think Techno Campus, B Wing –2nd Floor, Pokhran Road –2, Off Eastern Express Highway
Behind TCS, Thane West – 400607

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 Insured person may also approach the grievance cell at any of the company's branches with the details of
grievance.

lf lnsured person is not satisfied with the redressal of grievance through one of the above methods, insured
person may contact the grievance officer at [email protected] or call at: 7900197777

For updated details of grievance officer, kindly refer the link https://general.futuregenerali.in/general-
insurance/pdf/Grievance_Redressal_Procedures.pdf

lf lnsured person is not satisfied with the redressal of grievance through above methods, the insured person
may also approach the office of lnsurance Ombudsman of the respective area/region for redressal of
grievance as per lnsurance Ombudsman Rules 2017. Kindly refer the annexure on Grievance Redressal
Procedures.

Grievance may also be lodged at IRDAI Integrated Grievance Management System - https:/igms.irda.gov.in/

II. Specific Terms and Clauses

7. Claims procedure
i. If the Insured Person(s) meets with an accidental bodily injury that may result in a claim, then
a) Insured Person(s) must immediately consult a Medical Practitioner and follow the medical advice and
treatment that he recommends
b) Insured Person(s) must take reasonable steps to lessen the consequences of his bodily injury.
c) Insured Person(s) or someone claiming on his / her behalf must promptly give us the documentation
including claim form with necessary Medical Certificate and other information we ask for to investigate the
claim or Our obligation to make payment for it.
d) Insured Person(s) must have himself / herself examined by our medical advisors if we ask for and such
examination cost would be borne by us.
e) In case of hardships faced by the insured person(s) or person claiming on behalf of the insured person(s)
the conditions as specified under (4) below will be waived for which the insured person(s) or anyone
claiming on behalf has to justify delay with documentation.

ii. Immediately after the occurrence of an accident which may give rise to a claim under the policy, the insured
person(s) or the nominee (in case of death of the insured person(s)) shall contact the bank branch where the
insured person(s) held the underlying Bank Account from which the premium for the policy was auto debited
and submit a duly completed claim form.

iii. The claim form may be obtained from the bank branch or any other designated source like insurance
company branches, hospitals, PHCs, BCs, insurance agents or designated websites. The company shall ensure
wide availability of forms at all such locations.

iv. The Claim form shall be completed by the insured person(s) or, as the case may be, by the nominee and
submitted to the bank branch preferably within 30 days of the occurrence of the accident giving rise to the
claim under the policy.

v. The Claim form shall be supported, in case of death of the insured person(s), by the Original FIR/
Panchnama, Post Mortem Report and Death Certificate and in case of permanent disablement, by Original
FIR/ Panchnama and a Disability Certificate issued by a Civil Surgeon. A discharge certificate in the format
specified under the scheme shall also be submitted by the claimant / nominee.

vi. The authorised official of the Bank shall check the account / auto-debit particulars and verify the account
details, nomination, debiting of premium / remittance to insurer and certify the correctness of the information
given in the claim form, and forward the case to the insurance company within 30 days of the submission of
the claim.

vii. The Company will verify and confirm that premium has been remitted for the insured person(s) and the
insured person(s) is included in the list of insured persons in the master policy.

viii. Claim shall be processed by the Company within 30 days of its receipt from the Bank.

ix. The admissible Claim amount will be remitted to the Bank Account of the insured person(s) or the nominee in
case of a death claim. The discharge given in the Discharge form for the claim amount payable under the
policy by the accountholder of the bank or the nominee would be considered as full and final under the policy.

x. In case of death of an insured person(s) who has not named his/ her nominee the admissible claim amount
shall be paid to the legal heirs of the insured person(s) on production of Succession Certificate/ Legal Heir
certificate from the Competent Court/ authority.

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 xi. Maximum time limit for Bank to forward duly completed claim form to the Company is thirty days and
maximum time limit for Insurance Company to approve claim and disburse money thereafter is thirty days on
receipt of completed claim documents.

xii. Any communication should be sent to us in writing to Our address shown in the Schedule of the policy.

8. Settlement of Claim
i. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt of last
necessary document.
ii. ln the case of delay in the payment of a claim, the Company shall be liable to pay interest to the policyholder
from the date of receipt of last necessary document to the date of payment of claim at a rate 2% above the
bank rate.
iii. However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it shall
initiate and complete such investigation at the earliest, in any case not later than 30 days from the date of
receipt of last necessary document- ln such cases, the Company shall settle or reject the claim within 45 days
from the date of receipt of last necessary document.
iv. ln case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the policyholder at a
rate 2% above the bank rate from the date of receipt of last necessary document to the date of payment of
claim.
v. (Explanation: "Bank rate" shall mean the rate fixed by the Reserve Bank of lndia (RBl) at the beginning of the
financial year in which claim has fallen due)
vi. We will send any communication meant to Insured Person(s) to his / her address shown in the Schedule.
vii. Pending claims will be asked for submission of incomplete documents.
viii. Rejected claims will be informed to the Insured Person(s) in writing with reason for rejection.
ix. We will make all claim payments in Indian rupees within India only.
x. The Insured / Insured Person(s) / Nominee should not make any claim knowing it to be false or fraudulent in
any way.
xi. The Insured / Insured Person(s) / Nominee should also not conceal, misrepresent intentionally or otherwise
any fact or circumstance that we consider as material to acceptance of this insurance.
xii. If the Insured / Insured Person(s) / Nominee do so then the policy shall be void and all claims or payments due
under it shall be lost.

9. Renewal
i. The renewal of this Policy will be by mutual consent and as per the rates, terms and conditions of the Pradhan
Mantri Suraksha Bima Yojana prevalent at the time of renewal. The renewal premium shall be paid to us on or
before the date of expiry of the Policy or of the subsequent renewal thereof. The policy may be renewed on
annual basis.
ii. The Policyholder, shall throughout the period of insurance keep and maintain a record containing the names of
all the insured persons. The Policyholder shall declare to the company any additions in the number of insured
persons as and when arising during the period of insurance and shall pay the additional premium as agreed
iii. It is hereby agreed and understood that, this insurance being a group policy availed by the Insured covering
members, the benefit thereof would not be available to members who cease to be part of the group for any
reason whatsoever.
iv. Such members may obtain further individual insurance directly from the Company and any claims shall be
governed by the terms thereof.
v. The premium rates or loadings for the product would not be changed without approval from Authority. However
the performance of the product will be reviewed annually and further pricing will be done on experience basis

10. Termination of Cover

The accident cover for the member shall terminate on any of the following events and no benefit will be payable
there under:
i. On attaining age 70 years.
ii. Closure of account with the Bank or insufficiency of balance to keep the insurance in force.
iii. In case a member is covered through more than one account and premium is received by the Insurance
Company inadvertently, insurance cover will be restricted to one only and the premium shall be liable to be
forfeited.
iv. If the insurance cover is ceased due to any technical reasons such as insufficient balance on due date or due to
any administrative issues, the same can be reinstated on receipt of full annual premium, subject to conditions
agreed between the Bank and the Insurance Company. During this period, the risk cover will be suspended and
reinstatement of risk cover will be at the sole discretion of Insurance Company.
v. Participating banks will deduct the premium amount in the same month when the auto debit option is given,
preferably in May of every year, and remit the amount due to the Insurance Company in that month itself.

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 11. Cancellation
i. The Company may cancel the policy at any time on grounds of misrepresentation non-disclosure of material
facts, fraud by the insured person by giving 15 days' written notice. There would be no refund of premium on
cancellation on grounds of misrepresentation, non-disclosure of material facts or fraud.
ii. The Company shall refund a pro-rata premium for the unexpired Policy Period after deducting full premium for
members who have claimed under the policy.
iii. If the Insured wishes to cancel this policy Insured should give us 15 days notice in writing. We shall refund the
Insured balance premium after retaining premium as per the short term scale for the unexpired Policy Period
as well as full premium for the members who have claimed under the policy as shown below:
Policy Period not exceeding % of annual rate
1 month 25%
3 months 40%
6 months 75%
9 months 90%

12. Review of Premium

As per the Pradhan Mantri Suraksha Bima Yojana of the Government of India, the premium would be reviewed
based on annual claims experience.

13. Dispute Resolution

Any and all disputes or differences under or in relation to this Policy shall be subject to the exclusive jurisdiction of
the Indian Courts and subject to Indian law.

14. Territorial Limits and Law

i. We cover Accidental Bodily injury sustained by the Insured Person(s) during the Policy Period anywhere in the
World, but We will make payment within India and in Indian Rupees. The construction, interpretation and
meaning of the provisions of this Policy shall be determined in accordance with Indian Law.
ii. The Policy constitutes the complete contract of insurance between Us and Insured Person(s). No change or
alteration shall be valid or effective unless approved in writing by Us, which approval shall be evidenced by an
endorsement on the Schedule.

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 PRADHAN MANTRI SURAKSHA BIMA YOJANA (PMSBY)
CLAIM FORM
This form is issued without admission of liability. It must be completed and submitted to the branch where
the insured holds the underlying Bank Account, preferably within 30 days of the accident resulting in claim.
01 Name of the Account holder (Insured person)
02 Full address of the Insured:
03 Name and address of the Bank Branch:
04 Savings Bank Account Number:
05 Contact details of insured (if available):
Mobile No:
Phone number:
email address:
Aadhar no. if available:
06 Details of Nominee (in case of death of insured):
Name:
Mobile / Phone number:
Email address:
Bank Account Particulars (for electronic transfer):
Aadhar no. if available:
07 Details of Accident.
a) Day, Date, and Time of occurrence:
b) Where did it occur:
c) Nature of Accident:
d) Cause of Death/Details of Injury:
08 Name address and contact details of Hospital/
attending Doctors:
09 State where and when a Medical or other Officer of the
Company can visit the Insured.
10 Documents to be Submitted in support of the Claim:
a) In case of Death: Original FIR/ Panchnama, Post
Mortem Report and Death Certificate.
b) In case of Permanent Disablement: Original FIR/
Panchnama and Disability Certificate from Civil
Surgeon.
c) Discharge voucher

Declaration: I hereby declare and warrant that the foregoing particulars are true and complete in every
respect and I agree that if any of the details given above are proved to be false or untrue, or there is any
suppression or concealment, my right of compensation shall be forfeited. I also declare that I have not
claimed the amount due under PMSBY cover on account of the above accident through any other cover
under PMSBY.

Dated: Signature of the Claimant/Nominee.

For Office Use:
Policy Number: Claim Number:

Certified that the information relating to the Bank Account and Nominee has been verified. Premium was
debited to the Bank Account on ..................... and remitted to the insurer on:..................................

Signature of Authorised Official of the Bank

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 PRADHAN MANTRI SURAKSHA BIMA YOJANA
DISCHARGE VOUCHER

Claim No. :( to be filled by Bank) Policy No.:

Name of Bank / branch: Name of Insured:

Bank Account No. of Insured: Date:

In Consideration of approval of my claim referred above, I/We hereby accept from (name of the Insurance
Company) the sum of Rs. (approved net Claim amount) in full and final settlement of my/our claim arising
out of . . . . . . . . .which occurred on (date of loss) covered under Policy No. . . . . . . . .. . valid for the period
from..........to......................

I/We hereby voluntarily give discharge receipt to the Company in full and final settlement of all
my/our claims present or future arising directly/indirectly in respect of the said loss/accident.
I/We hereby also subrogate all my/our rights and remedies to the Company in respect of the
above loss/damages.

One Rupee Rev. Stamp

Signature of the Nominee /Insured.

Full Name:
Address:
Account No of Nominee:

Witness
Full Name
Address

Counter Signature of Authorised Official of the Bank

Bank Name & Branch:

Address:

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Authorization for Transfer of Claim Amount by National Electronic Fund Transfer

Name as per Bank Account

Bank Name
Branch Name & Address
Branch Phone No.
Branch MICR Code
Branch IFSC Code for NEFT
(Please attach a Photocopy of a cheque or a blank cheque of your bank duly cancelled for ensuring accuracy of the
bank name, branch name, account number & name of account holder printed)
Account Type (Please Tick) □ Savings □ Current □ Cash / Credit
Account No. (As appearing in
Cheque Book)

HR Authorization & Stamp Bank Authorization & Stamp

Date from which the mandate should be effective: _______________________

I hereby declare that the particulars given above are correct and complete and request you to remit any amount
due to me, if any to the aforesaid bank account. I herewith further declare that if any transaction is delayed or not
effected at all or is wrongly credited to any other account for reasons of incomplete or incorrect information as
provided above, I shall not hold Future Generali India Insurance Company Ltd (“Company“) or any of its directors,
employees or agents responsible for the same. I also declare that the remittance of any dues to the aforesaid
bank account shall be considered as full and valid discharge of its obligations by the company. I also undertake to
advise any change in the particulars of my bank account to facilitate updation of records for the purpose of credit
of any amount due, through NEFT.

Name of Employee / Proposer: ________________________Signature of Employee / Proposer______________

Policy No.: ________________________Claimant Name: _________________________Date: _____________

FEEDBACK AND SUGGESTIONS

We thank you for choosing Future Generali as your Insurance provider. We always strive to ensure that our
service levels exceed our customer’s expectations. In the spirit of this endeavour, we will greatly appreciate your
valuable inputs and feedback. Kindly provide your feedback on your experience with Future Generali and any
suggestions for improving our services. We value your time and promise to evaluate your suggestions for
improvement of our service.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Future Generali India Insurance Company Limited. IRDAI Regn. No. 132 | CIN: U66030MH2006PLC165287.
Regd. and Corp. Office: 801 and 802, 8th floor, Tower C, Embassy 247 Park, L.B.S. Marg, Vikhroli (W), Mumbai – 400083. Call us at: 1800-220-233 / 1860-500-3333 /
022-67837800 | Fax No: 022 4097 6900 | Website: https://general.futuregenerali.in | Email: [email protected]. Trade Logo displayed above belongs to M/S
Assicurazioni Generali - Societa Per Azioni and used by Future Generali India Insurance Co Ltd. under license.

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 Grievance Redressal Procedures

Dear Customer,

At Future Generali we are committed to provide “Exceptional Customer-Experience” that you remember and
return to fondly. We encourage you to read your policy & schedule carefully. We want to make sure the plan is
working for you and welcome your feedback.

What Constitutes a Grievance?

“Complaint” or “Grievance” means expression (includes communication in the form of electronic mail or other
electronic scripts, Inbound Call, SMS, Letter), of dissatisfaction by a complainant with insurer, distribution channels,
intermediaries, insurance intermediaries or other regulated entities about an action or lack of action about the
standard of service or deficiency of service of such insurer, distribution channels, intermediaries, insurance
intermediaries or other regulated entities;
Explanation: An Inquiry/Query or Request would not fall within the definition of the “complaint” or “grievance”.

“Complainant” means a policyholder or prospect or any beneficiary of an insurance policy who has filed a complaint or
grievance against an insurer or a distribution channel

If you have a complaint or grievance you may reach us through the following avenues:

Help Lines 1800-220-233 / Email [email protected]

1860-500-3333 /
022-67837800 Website https://general.futuregenerali.in/

GRO at each Walk-in to any of our branches and request to meet the Grievance Redressal
Branch Officer (GRO).

What can I expect after logging a Grievance?

• We will acknowledge receipt of your concern within 3 - business days.
• Within 2 - weeks of receiving your grievance, we shall revert to you the final resolution.
• We shall regard the complaint as closed if we do not receive a reply within 8 weeks from the date of
receipt of response.

How do I escalate?
• You can directly contact our Grievance Redressal Officer at our Head office.
 You can email to : [email protected] or call at: 7900197777
 You can write directly to our Grievance Redressal Cell at our Head office:

Grievance Grievance Redressal Cell, Future Generali India Insurance Company Ltd.
Redressal Lodha I – Think Techno Campus, B Wing – 2nd Floor, Pokhran Road – 2, Off Eastern
Cell Express Highway Behind TCS, Thane West – 400607.
Please send your complaint in writing. You can use the complaint form, annexed with your
policy.
Kindly quote your policy number in all communication with us. This will help us to deal
with the matter faster

What should I do, if I face difficulty in registering a grievance?

While we constantly endeavour to promptly register, acknowledge & resolve your grievance, if you feel that you are
experiencing difficulty in registering your complaint, you may register your complaint through the IRDAI
(Insurance Regulatory and Development Authority of India).
 CALL CENTER: TOLL FREE NUMBER (155255)
 REGISTER YOUR COMPLAINT ONLINE AT: HTTP://WWW.IGMS.IRDA.GOV.IN/

Grievances of Senior Citizens:

Now we have introduced a separate channel to address the grievances of our Senior Citizen customers. The concerns
will be addressed to the Senior Citizen's channel for faster attention or speedy disposal of grievance, if any. Senior
Citizens can register their complaints at [email protected]

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Insurance Ombudsman:
If you are still dissatisfied with the resolution provided or if it is already 30 days since you filed your complaint, you
can approach the office of Insurance Ombudsman, provided the same is under their purview. The guidelines for taking
up a complaint with the Insurance Ombudsman, along with their addresses are available on the consumer education
website of the IRDAI. http://www.policyholder.gov.in/Ombudsman.aspx
For ease of reference, the list of Insurance Ombudsmen offices is as mentioned below.

Office of the Contact Details Areas of Jurisdiction

Ombudsman
AHMEDABAD Office of the Insurance Ombudsman Gujarat, UT of Dadra & Nagar Haveli, Daman
6th Floor, Jeevan Prakash Building, Tilak Marg, Relief and Diu
Road,
AHMEDABAD - 380 001
Tel: 079-25501201/02/05/06
E-mail: [email protected]
BENGALURU Office of the Insurance Ombudsman Karnataka
Jeevan Soudha Building,PID No. 57-27-N-19 Ground
Floor, 19/19, 24th Main Road,JP Nagar, Ist Phase,
Bengaluru – 560 078. Tel.: 26652048 / 26652049
E-mail: [email protected]
BHOPAL Office of the Insurance Ombudsman Madhya Pradesh & Chhattisgarh
Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar,
Opp. Airtel Office, Near New Market, BHOPAL - 462
003
Tel: 0755 - 2769201 / 2769202 Fax: 0755-2769203
E-mail: [email protected]
BHUBANESHW Office of the Insurance Ombudsman Orissa
AR 62, Forest Park, BHUBANESHWAR - 751 009
Tel: 0674-2596461/2596455 Fax: 0674-2596429
E-mail: [email protected]
CHANDIGARH Office of the Insurance Ombudsman Punjab, Haryana (excluding Gurugram,
S.C.O. No.101 - 103, 2nd Floor, Batra Building, Faridabad, Sonepat and Bahadurgarh)
Sector 17-D, Himachal Pradesh, Union Territories of Jammu
CHANDIGARH - 160 017 & Kashmir, Ladakh & Chandigarh.
Tel: 0172-2706196/2706468 Fax: 0172-2708274
E-mail: [email protected]
CHENNAI Office of the Insurance Ombudsman Tamilnadu, UT- Puducherry Town and Karaikal
Fatima Akhtar Court, 4th Floor, 453, Anna Salai, (which are part of UT of Puducherry)
Teynampet,
CHENNAI - 600 018
Tel:044-24333668 /5284 Fax: 044-24333664
E-mail: [email protected]
DELHI Office of the Insurance Ombudsman Delhi & Following Districts of Haryana -
2/2 A, Universal Insurance Bldg. Asaf Ali Road, NEW Gurugram, Faridabad, Sonepat & Bahadurgarh.
DELHI - 110 002 Tel: 011-2323481/23213504
E-mail: [email protected]

GUWAHATI Office of the Insurance Ombudsman Assam, Meghalaya, Manipur, Mizoram,

Jeevan Nivesh, 5th floor Nr. Panbazar Overbridge, Arunachal Pradesh, Nagaland and Tripura
S.S. Road,
GUWAHATI - 781 001
Tel:0361-2632204/2602205
E-mail: [email protected]
HYDERABAD Office of the Insurance Ombudsman Andhra Pradesh, Telangana and UT of
6-2-46 , 1st Floor, Moin Court Lane, Opp. Saleem Yanam - a part of UT of Puducherry
Function Palace, A.C.Guards, Lakdi-Ka-Pool,
HYDERABAD - 500 004
Tel: 040-23312122 Fax: 040-23376599
E-mail: [email protected]

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JAIPUR Office of the Insurance Ombudsman Rajasthan
Jeevan Nidhi – II Bldg., Gr. Floor, Bhawani Singh
Marg, Jaipur - 302 005. Tel : 0141-2740363
E-mail: [email protected]
ERNAKULAM Office of the Insurance Ombudsman Kerala, UT of
2nd Floor, Pulinat Building, Opp. Cochin Shipyard, (a) Lakshadweep,
M.G. (b) Mahe - a part of UT of Puducherry
Road, ERNAKULAM - 682 015
Tel: 0484-2358759/2359338 Fax: 0484-2359336
E-mail: [email protected]
Office of the Insurance Ombudsman West Bengal, Sikkim and UT of Andaman &
KOLKATA Hindusthan Bldg. Annexe, 4th Floor,4, Nicobar Islands
C.R.Avenue, KOLKATA - 700 072 Tel: 033-
22124339 /40 Fax: 033-22124341
E-mail : [email protected]
LUCKNOW Office of the Insurance Ombudsman Districts of U.P:-
6th Floor, Jeevan Bhawan, Phase 2, Nawal Kishore Laitpur, Jhansi, Mahoba, Hamirpur, Banda,
Road, Hazratganj, Chitrakoot,
LUCKNOW - 226 001 Allahabad, Mirzapur, Sonbhabdra, Fatehpur,
Tel: 0522 -2231331/30 Fax: 0522-2231310 Pratapgarh, Jaunpur, Varanasi, Gazipur,
E-mail: [email protected] Jalaun, Kanpur, Lucknow, Unnao, Sitapur,
Lakhimpur, Bahraich, Barabanki, Raebareli,
Sravasti, Gonda, Faizabad, Amethi,
Kaushambi, Balrampur, Basti,
Ambedkarnagar, Sultanpur, Maharajgang,
Santkabirnagar, Azamgarh, Kushinagar,
Gorkhpur, Deoria, Mau, Ghazipur,
Chandauli, Ballia, Sidharathnagar
MUMBAI Office of the Insurance Ombudsman Goa and Mumbai Metropolitan Region excluding
3rd Floor, Jeevan Seva Annexe, S.V.Road, Santacruz Areas of Navi Mumbai & Thane
(W), MUMBAI - 400 054 Tel:
69038821/23/24/25/26/27/28/28/29/30/31 Fax:
022-
26106052 E-mail: [email protected]
NOIDA Office of the Insurance Ombudsman Bhagwan Sahai State of Uttaranchal and the following Districts
Palace of Uttar Pradesh: Agra, Aligarh, Bagpat,
4th Floor, Main Road, Naya Bans, Sector 15, Distt: Bareilly, Bijnor, Budaun, Bulandshehar, Etah,
Gautam Buddh Nagar, U.P-201301. Kanooj, Mainpuri, Mathura, Meerut,
Tel.: 0120 - 2514252 / 2514253 Moradabad, Muzaffarnagar, Oraiyya, Pilibhit,
Email: [email protected] Etawah, Farrukhabad, Firozbad,
Gautambodhanagar, Ghaziabad, Hardoi,
Shahjahanpur, Hapur, Shamli, Rampur,
Kashganj, Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.
PATNA Office of the Insurance Ombudsman 2nd Floor, Lalit Bihar and Jharkhand
Bhawan,
Bailey Road, Patna 800 001.
Tel.: 0612-2547068
Email: [email protected]
Office of the Insurance Ombudsman Maharashtra, Area of Navi Mumbai and Thane
PUNE Jeevan Darshan Bldg., 3rd Floor, C.T.S. No.s. 195 to but excluding Mumbai Metropolitan Region
198, N.C. Kelkar Road, Narayan Peth, Pune – 411
030.
Tel: 020-41312555
E-mail: [email protected]

The updated details of Insurance Ombudsman are available on IRDA website: www.irdai.gov.in, on the website of
Office of Executive Council of Insurers: https://www.cioins.co.in our website www.futuregenerali.in or from any of our
offices.

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 FORM FOR
REQUEST / COMPLAINT / FEEDBACK / APPRECIATION

I want to submit a □ Request □ Complaint □ Suggestion / Feedback □ Appreciation

Policy Type □ Motor □ Health □ Personal Accident □ Other _________________________
Policy Details □ Policy No. □ Claim No. □ Cover Note □ Health Card □ Existing Service Request

Customer Name _______________________________________________________________________________

Address ________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

City: ____________ Pin code: _____________ Telephone No. : _____________ Mobile No. : ____________

Detailed Description __________________________________________________________________________

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Date D D M M Y Y Y Y ________________________

Customer’s Signature

You may submit the form to the Nearest Branch Office or mail it to our Customer Service Cell at:
Customer Service Cell | Future Generali India Insurance Company Ltd.
Registered and Corporate Office: 801 and 802, 8th floor, Tower C, Embassy 247 Park, L.B.S. Marg, Vikhroli (W),
Mumbai – 400083, Maharashtra. Website: https://general.futuregenerali.in | Email: [email protected] | Call us
at: 1800-220-233 / 1860-500-3333 / 022-67837800
------------------------------------------------------------------------------------------------------------------------------------
For office use only Service / Case #

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Comments
____________________________________________________________________________
____________________________________________________________________________

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