PRADHAN MANTRI SURAKSHA BIMA YOJANA

NAME OF INSURER NAME OF BANK I POST OFFICE

I LOGO I LOGO OF I LOGO I
SCHEME

CONSENT-CUM-DECLARATION FORM

I hereby give my consent to become a member of ' Pradhan Mantri Suraksha Bima Yojana' of
............ (Name of Insurer) which will be administered by your Bank / Post Office under Master
Policy No ................................................ (To be pre-printed)

I hereby authorize you to debit my Account with your Branch with Rs. 12/-(Rupees twelve only),
towards premium of accidental insurance cover@ of Rs two lakhs under PMSBY (claim payable in
case of death or pe1manent disability# due to accident5) . I further authorize you to deduct in future after
25th May and not later than on l51 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 revise d, towards renewal of coverage under the scheme.

I have not authorized any other Bank / Post Office to debit premium in respect of this scheme. I am
aware that in case of multiple enrolments for the scheme by me, my insurance cover will be restricted
to Rs.two lakhs only and the premium paid by me for multiple enrolments shall be liable to be
forfeited.

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

I authorize the Bank /Post Office to convey my personal details, given below, as required, regarding
my admission into the group insurance scheme to................ (Name of lnsurer)

Name of the account Father's I husband's

holder** name**
Bank / Post Office IFSC Code of Bank
Account No.** Branch**
PAN Number, if AADHAAR Number, if
available** available**
Date of birth ** E-mail Id**

Whether suffe1ing If yes, details thereof

from any disability
Name and address of Date of Birth of nominee
nominee
Relationship of nominee
with the account holder
Name and address of Relations hip of the
Guardian / appointee guardian appointee
(if nominee is minor) with the nominee
Mobile number of Mobile number of
nominee guardian / appointee
Email id of nominee Email id of guardian /
appointee

1
 I hereby enclose a copy of my ------------------as proof of my identity (KYC*) and nominate my
nominee as above under this scheme. Nominee being minor, his / her guardian is appointed as above.

* Either of AADHAAR card or Electoral l Photo Identity Card (EPIC) or MGNREGA card or Driving
License or PAN card or Passport

I hereby declare that the above statements are true in all respects and that I agree and declare that the
above information shall fo1m the basis of admission to the above scheme and that if any infotmation be
found untrue, my membership to the scheme shall be treated as cancelled.

Date: Signature
Address:
Conformed that the applicant' s details** and signature have been verified from the records available
with this Bank / Post Office (or KYC document submitted* by the applicant, in case it is not available
with the bank / Post Office).

Signature of the Bank / Post Office Official

Date:
(Rubber Stamp with bank /Post office branch name and code)

For Office Use

Name of Agent / Agency/BC Code

Banking No.
Correspondent's (BC)
Bank Ale details of Signature of
Agent/BC Agent/BC

ACKNOWLEDGEMENTSLIP CUM CERTIFICATE OF INSURANCE

We hereby acknowledge receipt of "Consent-cum-Declaration Form " from Shri / Ms..

. . .. . . . . .. . .. . . .. .. . . .. . .. .. .. . . .. . .. . . holding Bank /Post Office Account
No.... ... .... .. ......... .... ..... ... .... Aadhar No ........................................... consenting and authorizing
auto-debit from the specified Bank /Post Office account to join the Pradhan Mantri Suraksha Bima
Yojana with ------------------ (Name of the Insurer) for cover under Master Policy No..
.. .. .... ... .. .. .. .. .. .. .. ., subject to correctness of information provided regarding eligibility andreceipt
of consideration amount.
Signature of authorised official of Bank / Post Office
Date:
Office Seal
Notes:
@ Insurance cover:

Claim of Rstwo lakhs payable in case of total disability or death due to accident
Claim of Rs one lakh payable in case of permanent pa1iial disability
$ Permanent Disability means any of the following:
Permanent Total Disability-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
Pe1manent Partial Disability-Total and irrecoverable loss of sight of one eye or loss of use of one hand
or foot
Accident means a sudden, unforeseen and involuntary event caused by external, violent and visible
means.

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 PRADHAN MANTRI SURAKSHA BIMA YOJANA (PMSBY)
CLAIM-CUM-DISCHARGE FORM 'VI
(To be submitted preferably within 30 days of the occurrence of the accident of the insured member
giving rise to the claim)

To be filled by the insured member in case of his accidental disability claim or by his
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 claimant2 legal heirs of the insured)
Part 1.Details of the member enrolled under PMSBY

(1) Name:

(2) Address:

(3) Bank / post office account number:

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

(5) Place of occurrence:

(6) Nature of accident:

(7) Date of death:

(8) Cause of death I disability 4(please specify):

(9) Details of disability:

(10) Document attached as proof of permanent disability5 / death :

(11) Aadhaar number7 (Optional):

(12) Income-tax Permanent Account Number (PAN)7 (Optional):

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 claimant2 legal heirs of the insured)

1. Name of the nominee:

2. Age of nominee:

3. In case the nominee is a minor, name of the appointee':

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

claimant2:

5. Proof of death6 of nominee in case of nominee pre-deceasing the insured member:

6. Relationship of the nominee/claimant with the deceased:

7. Contact mobile number:

8. Contact email address:

9. Contact address:
10. Details of the nominee/appointee /claimant (as the case may be):
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 (1) Particulars of bank account into which the claim amount is to be remitted:

(a) Account number:

(b) Name of bank:
(c) Branch IFS Code:
(2) Aadhaar number7(Optional):
(3) Income-tax PAN7(Optional):
(4) KYC document8 attached as proof of identity:

I hereby declare that details submitted above are true to the best of my knowledge, the
documents attached in support of this claim are genuine, and I have not claimed the amount
payable under PMSBY in respect of the member named above earlier or in respect of any other
account of the member with any bank or post office.

Date:
(Signature of the insured member/
nominee/appointee1/claimant2)

Attached documents:

(1) Proof of permanent disability due to accidents or death due to accident6 of the insured
member, as the case may be

(2) Aadhaar and PAN number of the insured member and claimant7(Optional)

(3) KYC document8 in respect of the nominee/appointee/claiant(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) Proof of death6 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 I Post office from enrolment data or data of bank/ 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):

2. Bank / post office name:

3. Branch name:

4. Branch IFS Code:

5. Name of father/husband of the member:

6. Date of birth (as per the KYC document):

4
 7. Name of the insurer:

8. Name of the nominee:

9. Date of debit of premium from the bank/ post office account:

10. Date of remitting the premium into insurer' s account:

It is certified that the above information is true as per PMSBY enrolment data and bank / post
office records.
Place:
Date:
(Signature and seal of the authorized official 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 from _ _ _ _ _

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

Signature of the witness

Name of witness:
Address:
Signature of the insured member/nominee/appointee/claimant
Date:

Countersignature of authorised official of the bank/ post office

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

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 Useful information for claimants
1
The appointee is the person named by the member in his PMSBY enrolment form where the
nominee is a minor.

2
A claimant where there is no nomination or the nominee has pre-deceased the insured member
shall be one who is a legal heir and submits a succession certificate or legal heir certificate issued
by a competent authority.

3 Accident means a sudden, unforeseen and involuntary event caused by external, violent and
visible means.

4
Pennanent Disability means any of the following:

Total and irrecoverable loss of both eyes or loss of use of Total disability-
both hands or feet or loss of sight of one eye and loss of claim amount payable is
use of one hand or foot Rs two lakhs
Total and irrecoverable loss of sight of one eye or loss of Partial disability-
use of one hand or foot Claim amount payable is
Rs one lakh

5
Documents in support of proof of permanent disability:
FIR or Panchnama, along with (a) Disability certificate issued by the Civil surgeon and
(b) hospital record supporting the same.

6
Documents in support of death due to accident may be any of the following:
(1) (a), (b) and (c) as under:
(a) Any of the documents listed below as proof of death:
(i) Death certificate (issued by the registrar of births and deaths appointed by
the state government for the local area)
(ii) Hospital discharge summary/certificate in respect of the deceased person,
specifying his/her name, father's/husband' s name, address and the date, time and
cause of death
(iii) Certificate issued by the last attending Registered Medical Practitioner
(doctor registered with the Indian Medical Council) in respect of the
deceased person, specifying his/her name, father's/husband's name, address
and the date, time and cause of death, which should be countersigned with
his/her seal by a Gazetted officer of the Central or the State Government or
by an officer of the deceased accountholder 's bank or any public sector bank or
any public sector insurer
(b) FIR/ Panchnama
(c) Post Mo1tem report

(2) Certificate issued in respect of the insured member by the District Magistrate /
Collector I Deputy Commissioner of the district concerned, or by any Executive
Magistrate (Additional District Magistrate, Sub-Divisional Magistrate, Tehsildar
/Taluk , etc.) authorised by him/her, in the form prescribed in the claim settlement
procedure for the scheme

(3) In case of death due to accidents such as snake bite/ fall from tree, etc., hospital record
specifying the deceased member's name, father' s/husband' s name, address and the date,
time and cause of death in lieu of (a), (b) and (c) above.
This information is desirable but not mandatory.8 Document in suppo1t of applicant ' s identity may be
Aadhaar card or electoral photo identity card [EPIC] or MGNREGA card or driving license or PAN
card or passport.
6
 PRADHAN MANTRI SURAKSHA BIMA YOJANA (PMSBY)
CLAIMS PROCEDURE
[Dated: 10.6.2021]

1. Immediately after the occurrence of an accident which may give rise to a claim under the
policy, the insured member in case of his accidental disability claim or his nominee in case of
death of insured member (or in case the nominee is a minor, his/her appointee1 , and in case of
no nomination or the nominee pre-deceasing insured member, the claimant legal heirs of the
insured) shall submit duly completed claim form to the concerned bank branch / post office
and preferably within 30 days of the occurrence of the accident3 giving rise to the claim
(death /permanent disability4) under the policy.

2. Bank/ post office to check whether claim is for disability or death (due to accident) of the
insured.

3. Bank / post office to check and confirm that the claim form has been submitted with
supporting documents as under:

(a) Proof of permanent disability due to accident5 or death due to accident6 of the insured
member, as the case may be
(b) Aadhaar and PAN number of the insured member and claimant7
(c) KYC document8 in respect of the nominee/appointee /claimant (as the case may be)
(d) 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)
(e) Proof of death6 of nominee in case of nominee pre-deceasing the insured member
(f) Proof of being legal heir, in case the claimant is other than the insured member/nominee
/appointee
(g) Advance receipt for discharge of claim, duly filled in and signed

4. The authorized official of the bank / post office shall check the account of the insured
member and confirm auto-debit particulars and the account detail s, nomination, debiting of
premium/ remittance to insurer and fill up the details of the insured member in the claim
form from the emolument data and records of bank / post office. He will certify the
correctness of the information given in the claim form and the duly completed check list for
the said claim.

5. Bank / post office to check KYC documents of nominee/ appointee/ claimant to establish his
identity and confirm that claim in respect of the said insured member has not been
forwarded to partner insurer by the bank / post office.

6. Bank / post office will forward the claim documents electronically to the designated email
id / app of the partner insurer within seven days of the submission of the claim.

7. Insurer will verify and confirm that premium has been remitted for the insured and the
insured is included in the list of insured persons in the master policy.

8. Insurer will also confirm whether the said claim under PMSBY has also been paid by any
other insurer or not, by way of a suitable deduplication mechanism. In case the same has
been paid, the Insurer may reject the claim.
7
 9. Claim shall be processed by the insurance company which has issued the master policy for
the bank / post office within seven days of its receipt from the bank / post office.

10. The admissible claim amount will be remitted to the bank / post office account of the insured
or the claimant, as the case may be.

11. In case there is no nomination or the nominee has predeceased the insured member the
admissible claim amount shall be paid to the legal heirs of the insured on production of
Succession Certificate / Legal Heir certificate from the competent court/authority.

12. Regardless of the claim being paid/ rejected, the insurer shall send an email/ app-based
intimation to the bank / post office and a text message alert to the mobile of the nominee
/ appointee / claimant, in addition to uploading the same on the Jan Suraksha portal
[https://www. jansuraksha.gov.in/MIS].

13. Maximum time limit for the bank / post office to forward duly completed claim form to
the insurer is seven days and maximum time limit for the insurer to approve claim and
disburse money thereafter is seven days.

14. In case the bank / post office has not remitted the premium amount debited from
the account of the insured member within the timeframe referred to in the rules
issued by DFS letter F. no. H-12011/2/2015-lns.II, dated 20.4.2015, the liability of
the claim shall be passed on to the bank / post office, and the claim form shall be
transmitted to the bank / Department of Posts. In case such a claim reaches the
insurer from the bank / post office, the insurer shall transmit it back for settlement
of the same, under intimation to the claimant.

15. The relaxations for accepting proof of death listed in Note no. 6 below, in view of
ongoing pandemic, would be valid up to 30.11.2021 or till further revision,
whichever is earlier. Further, claims pending as on date may also be settled on the
basis of these relaxations.
Notes:
1 The appointee is the person named by the member in his PMSBY enrolment form where the nominee
is a minor.

2
A claimant where there is no nomination or the nominee has predeceased the insured member shall be one
who is a legal heir and submits a succession certificate or legal heir certificate issued by a competent
court or authority.
,
3
Accident means a sudden, unforeseen and involuntary event caused by external, violent and visible
means.

4 Permanent
Disability means any of the following:

Total and irrecoverable loss of both eyes or loss of use of Total disability-
both hands or feet or loss of sight of one eye and loss of claim amount payable is
use of one hand or foot Rs two lakhs
Total and irrecoverable loss of sight of one eye or loss of Partial disability-
use of one hand or foot Claim amount payable is
Rs one lakh
5 Documents in support of proof of permanent disability: FIR. or Panchnama, along with (a) Disability certificate

issued by the Civil surgeon and (b) hospital record supporting the same.

8
 Documents in support of death due to accident may be any of the following:
(1) (a), (b) and (c) as under:
(a) Any of the documents listed below as proof of death:
(i) Death certificate (issued by the registrar of births and deaths appointed by the state
government for the local area)
(ii) Hospital discharge summary/certificate in respect of the deceased person, specifying
his/her name, father's/husband's name, address and the date, time and cause of death
(iii) Certificate issued by the last attending Registered Medical Practitioner (doctor
registered with the Indian Medical Council) in respect of the deceased person,
specifying his/her name, father's/husband's name, address and the date, time and
cause of death, which should be countersigned with his/her seal by a Gazetted officer of
the Central or the State Government or by an officer of the deceased accountholder's
bank or any public sector bank or any public sector insurer
(b) FIR/ Panchnama
(c) Post Mortem report

(2) Certificate issued in respect of the insured member by the District Magistrate / Collector /
Deputy Commissioner of the district concerned, or by any Executive Magistrate (Additional
District Magistrate, Sub-Divisional Magistrate, Tehsildar /Talukda, etc.) authorised by him/her,
in the form prescribed in the claim settlement procedure for the scheme

(3) In case of death due to accidents such as snake bite/ fall from tree, etc., hospital record specifying
the deceased member's name, father's /husband' s name, address and the date, time and cause of
death in lieu of (a), (b) and (c) above.

7This info1mation is desirable but not mandatory.

8
Document in support of applicant's identity may be Aadhaar card or electoral photo identity card
[EPIC] or MGNREGA card or driving license or PAN card or passport.

***