ANNEXURE -3(ovi PRADHAN MANTRI JEEVAN JYOTI BIMA YOJANA. 5 CONSENT-CUM-DECLARATION FORM be fled n by members orig the scheme on or afr 01.06.2016 For Offic pve IndiaFirst LIFE INSURANCE da sith aster Bank of Baroda Agen oos Name Tgency/B Code Non Bank Ne details ofAgondBO —* Signature of AgentBarking Corespondan? ‘hereby give my consanto become a mamber af Pradhan Mant Jeevan yot Bima Yojana’ of (Name ofnsure) which wile administered by your Bank under Master Policy No, (Tobe pre-printed) | eceby authorize you to debit my Savings Bank Account wth your Branch with Rs. plus Taxes if applicable wards prism fife cover under PMY, urherauthorz yuo deduct te due proriumin ure afer 25 Nay and nat arn on June ‘vary yoaruniluherinsbuctons,anamauntofRs________________andTaxesif applicable, or ary amounts dacided ‘fom time to time, which may be intimated immadlatly i and when rovsed, wards renewal of coverage unde the scheme, have not authorizes any other bank to debit premium in respect ofthis scheme. |r aware that my fe cover shall be restricted to Rs.200,00 ‘ony inthe evet of my death [nave fad and understod te Scheme rls and | hereby give my consent to become @ member ofthe Scheme. Lam aware thal he risk wilt be ‘covered dung the fist 45 days fromthe date of enrollment info the scheme (len peiod)_and incase of death (oer han due to accident) durin en period, no Gaim would be adrissbe | authorize the Bank to convey my personal dla, given below, as required, regarding my admission ino the group insurance scheme to (Name of insurer) Member ining ia month ‘Guarer ‘Total Premium be collected June, July gust Quarer- 1 330k ‘Sepiember, October, November Quarer=2 258 December, January. February Quarer=3 72 March, Ap May Quarer=4 88 ‘Applicant Details, as pet Bank KYC records: Tame of te Account heer [as per Bank records) ‘Savings Bank Account No. ‘achar Number Waves E-mail id Mabie No, Name, adaress and ‘Name and adaross of Guardan telaonsi if any) of nominee (nominee i mince Date of Birth ‘Agaress hereby nominate my nominee as above under is Scheme Nominee being minor, his her guardians appointed a above \proby declare that tho above slatoments are true in all respects and that agrae and daclare thatthe above information shal orm the bass of ‘admission tothe above scheme and tha any informaton be found untrue my membership tthe scheme shal be treated a canceled, Date: Signature ‘ares: Signature vriid (Branch Offa (Rubber Stamp wit bank branch name and cod) "AGKNOWLEDGEMENT SLIP CUM CERTIFICATE OF INSURANCE We hereby acknowedge receipt of “Consen-cum-Declaraton Form’ from Sh Smt hing Bank Account No. ‘achat No, ‘consenting and authorizing auio-debit rom the specied Bank Account join the Pradhan Wanti Jeevan Jyot Bima Yojana wih =———-—---- (Name of the Insurance Company) for cover under Master Poicy No, subject o corecness of information provided regarding eligbily and recent of consderaton amount Seal & Signature of Authorised Bank Offical Disclaimer: For more information on risk factors, terms & conditions please Bank of Baroda is the Corporate Agent of Indiairst Life Insurance, Corporate Agi 1 the sales brochure carefully before concluding a sal. License No: CA0004, |RDAI Reg. No. 143, IndiaFist Life Insurance Company Ltd, ‘ek-#9122 6165 8700 Fax: +9122 6270 0600 TollFree: 800-208-8700, 301,’ Wing, The Qube, Infinity Park, Dindoshi- Film City Road, ~ Malad (East), Mumbai - 400 097, CIN; US6OIOMH2O08PLCI83679, | Ema customer‘ indafettecom Wel