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Pmjjby Form Boi

The document is a consent-cum-declaration form for individuals joining the Pradhan Mantri Jeevan Jyoti Bima Yojana, allowing auto-debit of premium from their bank accounts. It outlines the terms of membership, including coverage details, lien period, and nominee information. The form must be verified by a bank official and includes an acknowledgment slip for the insurance coverage applied for.

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santosh kumar pramanik
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737 views1 page

Pmjjby Form Boi

The document is a consent-cum-declaration form for individuals joining the Pradhan Mantri Jeevan Jyoti Bima Yojana, allowing auto-debit of premium from their bank accounts. It outlines the terms of membership, including coverage details, lien period, and nominee information. The form must be verified by a bank official and includes an acknowledgment slip for the insurance coverage applied for.

Uploaded by

santosh kumar pramanik
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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ANNEXURE - 3(revised)

PRADHAN MANTRI JEEVAN JYOTI BIMA YOJANA

CONSENT-CUM-DECLARATION FORM
(To be filled in by members joining the scheme on or after 01.06.2016
For Office Use

Agent‟/BC‟s Name* Agency/BC Code No.*


Bank A/c details of Agent/BC
–*
Signature of Agent/Banking Correspondent*
I hereby give my consent to become a member of „Pradhan Mantri Jeevan Jyoti Bima Yojana‟ of Star Union Dai-ichi Life Insurance
Co. Ltd (Name of Insurer) which will be administered by your Bank under Master Policy No. JJ000001.

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 25 th 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 am aware that
the risk will not be covered during the first 45 days from the date of enrollment into the scheme (lien period) and in case
of death (other than due to accident) during lien period, no claim would be admissible.

I authorize the Bank to convey my personal details, given below, as required, regarding my admission into the group insurance
scheme to Star Union Dai-ichi Life Insurance Co. Ltd (Name of Insurer)

Applicant Details, as per Bank / KYC records:

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 Name and address of Guardian
relationship (if any) of (if nominee is minor)
nominee
Date of Birth Address

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)
__________________________________________________________
ACKNOWLEDGEMENT SLIP CUM CERTIFICATE OF INSURANCE

We hereby acknowledge receipt of “Consent-cum-Declaration Form” from Sh / Smt. ………………………………… holding Bank
Account No……………………………….. Aadhar No………………………….. consenting and authorizing auto-debit from the specified
Bank Account to join the Pradhan Mantri Jeevan Jyoti Bima Yojana with ------------------ (Name of the Insurance Company) for cover
under Master Policy No JJ000001, subject to correctness of information provided regarding eligibility and receipt of consideration
amount.

Seal & Signature of Authorised Bank Official

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