Professional Documents
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Claim Form
Claim Form
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
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
1. Bank/post office account number (as per bank's CBS/ post office records): G29 g02o|00 DS 60T
(x) IAM
Signature of the witness
Name of witness:
Address: member/nominee/appointee/claimant