BRANCH NAME BRANCH CODE ACCOUNT NUMBER DATE 01 NAME OF THE A/C HOLDER MOBILE NO DATE OF BIRTH GENDER Y EMAIL ID NOMINEE NAME RELATION SHIP IS NOMINEE MINOR ? YES sriklanth NOMINEE ADDRESS PACKAGE DESIGNED AND DEVELOPED BY HEARTLY THANKS TO HITHESH KUMAR.S SRIKANTH K STATE BANK OF INDIA STATE BANK OF INDIA MADIKERI BRANCH MADIKERI BRANCH CELL:9035555969 Email: [email protected]### EMAIL:[email protected]YOUR VALUED SUGGESTIONS FOR IMPROVEMENT OF THIS PACKAGE WILL BE ALWAYS WELCOME
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BRANCH NAME BRANCH CODE
ACCOUNT NUMBER DATE 01
NAME OF THE A/C HOLDER MOBILE NO
DATE OF BIRTH GENDERY
EMAIL ID00/00/0000
NOMINEE NAME RELATION SHIP
IS NOMINEE MINOR ? YES sriklanth
NOMINEE ADDRESS5/6/2012
PACKAGE DESIGNED AND DEVELOPED BY HEARTLY THANKS TO 3
Address for this policy will be the same as provided by me to the State Bank of India for my saving Bank a/ccitied above .
Gender 0 Date of Birth
Email id Mobile No 0
Kindly Note
1) Coverage is for Accidental Death (AD) only2) Period of insurance will be one year from the date of account debit transaction3)Occupation like serving in any branch of police, paramilitary, military and armed forces of any country whether in peace or war are not covered under this policy
DECLARATION* I hereby declare that the statements made by me in this Priposal Form are true belief amd complete in all respect* I agree that this proposdal and the declarations shall be the basis of the conctract betweenme and SBI General Insurance co ltd* I also declare that any changes in the information given above after the the submission of this would be conveyed to SBI General immedietly* I understand that this conctract/ transaction between SBI General Co ltd and myself State Bank of India is merely facilitating the purchase of this incurance policy and has no obligation towards settlement of claims* I have read the brief terms and conditions of the policy and confirm that I am eligible for coverage under this policy.
NOMINATION
Address of the Nominee/Guardian:0 0 0 0 0
Date : 0/01/0 Place : 0
Signature of the proposed insuredSECTON 471 OF INSURANCE ACT,1938No person shall or offer to allow either directly or indirectly as an inducement to any person to take out or renew or continue as
insurance in respect of any kind of risk relating to lives or property in india, any rebate of whole or part of the commission
payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy
accept any rebate except such rebate as may be allowed in accordance with the published prospectuses or tables of the
insurer
ANY PERSON MAKING DEFAULT IN COMPLING WITH THE PROVISION OF THIS SECTION SHALL BE PUNISHABLE WITH
FINE, WHICH MAY EXTEND TO FIVE HUNDRED REPEES.
For internal purpose only(To be filled by SBI Branch official)
Account No 0 Journal No: Date 0/01/0
Insurance is the subject matter of the solicitation
I 0 do hereby nominate Mr/ Mrs/ Ms 0 as the person and Mr/Mrs/miss sriklanth as Guardian of the nominee( in case nominee is a minor) to receive the amount payableby SBI General Insurance Co ltd in the event of my Accidental Death and he/she (nominee) is related to me as 0 (Relation to the Insured) and I further declare that his /her receipt shall be sufficient t the Company. Dated this 0JANUARY0 at 0
Corporate & Registered Office: Natraj,101,201 &301, Junction of Western Express Highway & Andheri-Kurla Road, Andheri (East) Mumbai 400069
DEBIT AUTHORISATION ADVISE Pay-in -Slip No:
To, From : Name : 0The Branch ManagerState Bank of India Tel/Mob : 0
0 Date : 0/01/0
Dear Sir,
I hereby authorise you to debit my saving Bank Acct No 0 for Rs 100/-(Rupees One hundred only) for the issuance of a SBI General Personal Accident Insurance Policy
Yours Faithfully,
Signature of Applicant
CREDIT VOUCHER Pay-in-Slip No
State Bank of India
Branch : 0
Date : 0/01/0
Credit Amount Rs.100/-(Rupees One hundred only) to Power Jyothi A/c32226116717(Premium Collection Account for SBI General Personal Accidental Insurance Policy).
This is to Certify that an amount of Rs.100/- (Rupees One hundred only) has been debited from the saving Bank Account No0 in the name of Mr/ Ms/ Mrs 0 towards premium of SBI General Personal Accidental Insurance Policy for Sum assured of Rs. 4 Lacs only.
Master Policy No: 137300-0000-00
GROUP PERSONAL ACCIDENT INSURANCE POLICYProposal Form
CALL(Toll Free)
Sbi Sving Bank a/c No. 1800221111/18001021111
Sbi Branch Name CODE:###### ###### 0 ###
Name of the proposed insured person
Address for this policy will be the same as provided by me to the State Bank of India for my saving Bank a/ccitied above .
Gender Date of Birth
Email id Mobile No
Kindly Note
1) Coverage is for Accidental Death (AD) only2) Period of insurance will be one year from the date of account debit transaction3)Occupation like serving in any branch of police, paramilitary, military and armed forces of any country whether in peace or war are not covered under this policy
DECLARATION* I hereby declare that the statements made by me in this Priposal Form are true belief amd complete in all respect* I agree that this proposdal and the declarations shall be the basis of the conctract betweenme and SBI General Insurance co ltd* I also declare that any changes in the information given above after the the submission of this would be conveyed to SBI General immedietly* I understand that this conctract/ transaction between SBI General Co ltd and myself State Bank of India is merely facilitating the purchase of this incurance policy and has no obligation towards settlement of claims* I have read the brief terms and conditions of the policy and confirm that I am eligible for coverage under this policy.
NOMINATION
Address of the Nominee/Guardian:………………….. ………………… …………… ………….. …………..
Date : Place :
Signature of the proposed insuredSECTON 471 OF INSURANCE ACT,1938No person shall or offer to allow either directly or indirectly as an inducement to any person to take out or renew or continue as
insurance in respect of any kind of risk relating to lives or property in india, any rebate of whole or part of the commission
payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy
accept any rebate except such rebate as may be allowed in accordance with the published prospectuses or tables of the
insurer
ANY PERSON MAKING DEFAULT IN COMPLING WITH THE PROVISION OF THIS SECTION SHALL BE PUNISHABLE WITH
FINE, WHICH MAY EXTEND TO FIVE HUNDRED REPEES.
For internal purpose only(To be filled by SBI Branch official)
Account No Journal No: Date
Insurance is the subject matter of the solicitation
I …………………….. do hereby nominate Mr/ Mrs/ Ms ………………… as the person and Mr/Mrs/miss ……………….. as Guardian of the nominee( in case nominee is a minor) to receive the amount payableby SBI General Insurance Co ltd in the event of my Accidental Death and he/she (nominee) is related to me as ……………… (Relation to the Insured) and I further declare that his /her receipt shall be sufficient t the Company. Dated this ……………………… at ………………….
Corporate & Registered Office: Natraj,101,201 &301, Junction of Western Express Highway & Andheri-Kurla Road, Andheri (East) Mumbai 400069
DEBIT AUTHORISATION ADVISE Pay-in -Slip No:
To, From : Name :The Branch ManagerState Bank of India Tel/Mob :
Date :
Dear Sir,
I hereby authorise you to debit my saving Bank Acct No for Rs 100/-(Rupees One hundred only) for the issuance of a SBI General Personal Accident Insurance Policy
Yours Faithfully,
Signature of Applicant
CREDIT VOUCHER Pay-in-Slip No
State Bank of India
Branch :
Date :
Credit Amount Rs.100/-(Rupees One hundred only) to Power Jyothi A/c32226116717(Premium Collection Account for SBI General Personal Accidental Insurance Policy).
This is to Certify that an amount of Rs.100/- (Rupees One hundred only) has been debited from the saving Bank Account No……………….. in the name of Mr/ Ms/ Mrs ……………………. towards premium of SBI General Personal Accidental Insurance Policy for Sum assured of Rs. 4 Lacs only.
