Declaration of "No other policy held under Pradhan Mantri Suraksha Bima Yojana (PMSBY)"

I have read and understood the Scheme rules and I hereby give my consent to become a member of the Scheme.

I declare that I am not insured under Pradhan Mantri Suraksha Bima Yojana (PMSBY) under any other Savings Bank Account. In case the same is found to exist, premium shall stand forfeited and no claims would be paid. I have not authorized any other bank to debit premium in respect of this scheme. I am aware that my Insurance cover under the said policy shall be restricted to Rs. 2,00,000/- in the event of accidental death or 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 and; Rs. 1,00,000/- in case of total and irrecoverable loss of sight of one eye or loss of use of one hand or foot.

I hereby authorize you to debit my Savings Bank Account with your Bank for Rs.12/- (Rupees Twelve Only) towards premium of accidental and disability cover under PMSBY. I further authorize you to deduct in future after 25th May and not later than on 1st of June every year until further instructions, an amount of Rs.12/- (Rupees twelve only), 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 or as per the prevalent terms and conditions of the scheme which may be subject to change.

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.

Declaration of “No other policy held under Pradhan Mantri Suraksha Bima Yojana (PMSBY)”

I have read and understood the Scheme rules and I hereby give my consent to become a member of the Scheme.

I declare that I am not insured under Pradhan Mantri Suraksha Bima Yojana (PMSBY) under any other Savings Bank Account. In case the same is found to exist, premium shall stand forfeited and no claims would be paid. I have not authorized any other bank to debit premium in respect of this scheme. I am aware that my Insurance cover under the said policy shall be restricted to Rs. 2,00,000/- in the event of accidental death or 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 and; Rs. 1,00,000/- in case of total and irrecoverable loss of sight of one eye or loss of use of one hand or foot.

I hereby authorize you to debit my Savings Bank Account with your Bank for Rs.12/- (Rupees Twelve Only) towards premium of accidental and disability cover under PMSBY. I further authorize you to deduct in future after 25th May and not later than on 1st of June every year until further instructions, an amount of Rs.12/- (Rupees twelve only), 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 or as per the prevalent terms and conditions of the scheme which may be subject to change.

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.