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  • Claim Form

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    UJJWAL RATHOD
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    1) This document is a claim form for benefits under the Pradhan Mantri Suraksha Bima Yojana insurance scheme in India. It collects details of the insured member who died or became disabled due to an accident, along with details of the nominee claiming the insurance payout. 2) It provides instructions on who should fill out the form depending on if the insured member is claiming for disability or if a nominee is claiming benefits due to the member's death. 3) The form collects identifying information about the insured member and nominee, along with documents to prove the member's death or disability and the nominee's identity and bank account to receive the insurance payout.

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    1) This document is a claim form for benefits under the Pradhan Mantri Suraksha Bima Yojana insurance scheme in India. It collects details of the insured member who died or became disabled due to an accident, along with details of the nominee claiming the insurance payout. 2) It provides instructions on who should fill out the form depending on if the insured member is claiming for disability or if a nominee is claiming benefits due to the member's death. 3) The form collects identifying information about the insured member and nominee, along with documents to prove the member's death or disability and the nominee's identity and bank account to receive the insurance payout.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    207 views3 pages

    Claim Form

    Uploaded by

    UJJWAL RATHOD
    1) This document is a claim form for benefits under the Pradhan Mantri Suraksha Bima Yojana insurance scheme in India. It collects details of the insured member who died or became disabled due to an accident, along with details of the nominee claiming the insurance payout. 2) It provides instructions on who should fill out the form depending on if the insured member is claiming for disability or if a nominee is claiming benefits due to the member's death. 3) The form collects identifying information about the insured member and nominee, along with documents to prove the member's death or disability and the nominee's identity and bank account to receive the insurance payout.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 3

    PRADHAN MANTRI SURAKSHA BIMA YOJANA (PMSBY) 20

    CLAIM-CUM-DISCHARGE FORM
    submitted preferably within 30 days of the occurrence of the accident of the insured member
    giving rise to the claim)

    o be filled by the insured member in case of his accidental disability claim or by his
    ominee in case of death of insured member
    (or in case the nominee is a minnor, his/her appointee', and in case of no nomination or
    the nominee
    pre-deceasing insured member, the claimant legal heirs of the insured)
    art 1. Details of the member enrolled under
    PMSBY
    (1) Name: Suresh bha Kanabhaf makwnq
    (2) Address: 3 86 Vag vas, anand , D r Anmed abad
    (3) Bank/ post office account number: C299o201oo o 56b

    (4) Day, date, and time of accident:


    u/o22022
    (5) Place of occurrence:
    njuryon Hea
    Acciden
    (6)
    (o) Nature ofaccident': Road

    (7) Date of death: o 2


    202
    (8) Cause ofdeath/disability'(please specify): Read Ace iden &tnj Hend
    9) Details of disability:
    (10) Document attached as proof of permanent disability'/ death

    (11) Aadhaar number'(Optional): 6 893 -So28 3 9


    (12) Income-tax Permanent Account Number (PAN)' (Optional): DGiPs 5 3 64 A

    Part 2. Details of the nominee in case of death of insured member:


    (or, in case the nominee is a minor, his/her appointee', and in case of no nomination or
    the nominee pre-deceasing insured member, the claimantf legal heirs of the insured)

    1. Name ofthe nominee: Semvaa Romilaben Sureshbha


    2. Age of nominee: 36 y
    3. In case the nominee is a minor, name ofthe appointee: NA

    4. In case of no nomination or nominee pre-deceasing the insured member, name of the


    claimant:

    5. Proof of death° of nominee in case of nominee pre-deceasing the insured member:

    6. Relationship ofthe nominee/claimant with the deceased: S Pouse

    7. Contact mobile number: 0|2.13166o


    8. Contact email address: Sen tas, To HP a SreaAd Aea
    A
    9. Contact address: Se nva Uas To motiPu
    -
    o. Sana ne, b
    10. Details ofthe nominee/appointee/claimant (as the case may be):
    () Particulars of bank account into which the claim amount is to be remitted: Unto
    06 Inda
    (a) Account number: 62g o 2o1 ooIS189
    (b) Name of bank: Oniom ane ob I d ia
    (c) Branch IFS Code:
    Uet n o 562 993
    (2) Aadhaar number
    (Optional): S321 -

    3o2g - S 7
    (3) Income-tax PAN'
    (Optional):
    (4) KYC document" attached as proof of identity: AadA co
    I hereby declare that details submitted above are true to
    documents attached in the best of my knowledge, the
    support of this claim are genuine, and I have not claimed the
    payable under PMSBY in respect of the member named above amount
    other account of the member with earlier or in respect or any
    any bank or post office.

    Date
    (Signature of the insured member
    nominee/appointee' /claimant)
    Attached documents:

    (1) Proof of permanent disability due to accident:5 or death due to acidentó of the insured
    member, as the case may be

    (2) Aadhaar and PAN number of the insured member and claimant'(Optional)

    (3) KYC document° in respect of the nominee/appointee/claimant (as the case may be)

    (4) First two pages of passbook, or bank/ post office account statement showing account
    details, or cancelled cheque of the account of the nominee/appointee/claimant (as the case
    may be)
    (5) Proofof death" of nominee in case of nominee pre-deceasing the insured member

    (6) Proof of being legal heir, in case the claimant is other than the insured
    member/nominee/appointee
    (7) Advance receipt for discharge of claim, duly filled in and signed

    To be filled by the bank/Post officefrom enrolnment data or data ofbank/post office

    Part 3: Details in respect of the insured member

    1. Bank/post office account number (as per bank's CBS/ post office records): G29 g02o|00 DS 60T

    On ion 8ank o6 ndq


    2. Bank / post office name:
    Sanand anch_
    3. Branch name:

    4. Branch IFS Code: OBIN OS6299&


    Kanab ha
    5. Name of father/husband of the member: Sueeghbha t s a a

    6. Date of birth (as per the KYC document): "to o y o1(o


    naktoana
    7. Name of the insurer: Sureshbho Kanab ha
    Senva Ramilaben suresLbha
    8. Name of the nominee:
    (SPoue
    ate
    Date of debit of premum from the bank/ post office account:
    9
    Date of remitting the premium into insurer's
    2 S|oS|202
    10. account:
    It is certified that the above information is true as per PMSBY enrolment data and bank/
    office records. post
    Place: Sana nd
    Date:
    (Signature and seal of the authorised officiat of the bank/post office)

    PRADHAN MANTRI SURAKSHA BIMA YOJANA


    Advance receipt for discharge of claim

    In consideration of approval of my claim referred above, I hereby accept irom,


    of
    (name of the insurer) the sum of Rs. (Rs. One lakh in case permanent
    death) only in rull
    partial disability and Rs. two lakhs in case of permanent total disability
    or
    insurance in
    and discharge of my claim under the said
    and final settlement policy covering
    respect of member Shri / Ms

    (x) IAM
    Signature of the witness
    Name of witness:
    Address: member/nominee/appointee/claimant

    Signature of the insured


    Date:

    authorised official of the bank/ post office


    Countersignature of
    Date
    Name:
    Name of bank/ post office:
    Branch:
    Office stamp

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