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    IOB Suraksha Proposal Form

    Uploaded by

    gurujm
    1. The document is an enrollment form for group personal accident insurance through Indian Overseas Bank. 2. It collects personal details of the insured such as name, address, phone, account number, date of birth, gender, occupation, sum insured, premium amount, and period of insurance. 3. The insured authorizes automatic debit of their bank account for payment of annual premiums and declares that all information provided is true to their knowledge.

    Copyright:

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

    IOB Suraksha Proposal Form

    Uploaded by

    gurujm
    221 views1 page
    1. The document is an enrollment form for group personal accident insurance through Indian Overseas Bank. 2. It collects personal details of the insured such as name, address, phone, account number, date of birth, gender, occupation, sum insured, premium amount, and period of insurance. 3. The insured authorizes automatic debit of their bank account for payment of annual premiums and declares that all information provided is true to their knowledge.

    Original Title

    IOB Suraksha Proposal Form (1)

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    1. The document is an enrollment form for group personal accident insurance through Indian Overseas Bank. 2. It collects personal details of the insured such as name, address, phone, account number, date of birth, gender, occupation, sum insured, premium amount, and period of insurance. 3. The insured authorizes automatic debit of their bank account for payment of annual premiums and declares that all information provided is true to their knowledge.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    221 views1 page

    IOB Suraksha Proposal Form

    Uploaded by

    gurujm
    1. The document is an enrollment form for group personal accident insurance through Indian Overseas Bank. 2. It collects personal details of the insured such as name, address, phone, account number, date of birth, gender, occupation, sum insured, premium amount, and period of insurance. 3. The insured authorizes automatic debit of their bank account for payment of annual premiums and declares that all information provided is true to their knowledge.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    IOB SURAKSHA

    ENROLLMENT FORM FOR GROUP PERSONAL ACCIDENT INSURANCE


    Branch Code
    Branch Name
    Master Policy Holder
    Master Policy No.
    Name of Insurer( Mr./Mrs./Ms.)
    Address of Insured
    Phone/Mobile No
    Email Id
    Account No./Customer ID
    Date of Birth(DD/MM/YYYY)
    Gender
    Occupation
    Sum Insured{ Plan A-Rs. 5lac, Plan B-Rs.10lacs}
    Annual Premium{Plan A-Rs.100+GST, Plan B-Rs.200+GST}
    Period of Insurance
    Whether suffering from any disability
    If yes, details thereof
    Name of the Nominee
    Relation with Nominee
    Name and Address of Guardian, if nominee is minor
    Declaration:
     I hereby authorize you to debit my account of Indian Overseas Bank with Rs.100/-(Rupees Hundred Only) Plus GST in case of Plan A and
    Rs.200/-(Rupees Two Hundred Only) Plus GST in case of Plan B.
    th
     I hereby authorise you to debit my account with Indian Overseas Bank on or before 13 April of every subsequent year until further
    instructions.
     I have read and understood the copy of master policy made available to me and I bind by the terms and conditions therein and I accept them.
    I also agree to become a member of group personal accident insurance cover with bank being the master policy holder.
     I undertake to pay the full annual premium irrespective of the joining period and also undertake to maintain sufficient balance in my account
    with Indian Overseas Bank and authorise the bank to debit stipulates annual premium plus applicable service tax from my account with Indian
    Overseas Bank 7 days in advance during every renewal.
     I hereby declare that the statement made by me in this Proposal form are true to the best of my knowledge and belief and I hereby agree that
    this declaration shall form the basis of the contract between me and the “Universal Sompo General Insurance Co. Ltd”
     I also declare that any changes in the nature of profession or any such material changes after the submission of this proposal form would be
    conveyed to you.
     I also declare that I have not taken multiple policies under the said IOB Suraksha scheme and even if there are Multiple Policies issued under
    the said scheme in my name. I would be entitled for claim under only one policy with the maximum benefit of Rs.5lacs in Plan A and Rs.10lacs
    in Plan B under the said scheme.
     I have read and understood the terms and conditions, coverages and exclusions mentioned overleaf of this application.
    Date:
    Place: Signature/Left Thumb Impression of Proposer
    Declaration in case the applicant is Illiterate:
    I hereby declare that I have explained the content of this application in ……………….language to the applicant. The same have been fully
    understood by him/her and replies have been recorded as per information provided by the applicant and the replies have been read out to,
    fully understood and confirmed by the applicant. The Applicant has affixed his/her left thumb impression in my presence.
    Declarant’s name: ……………………………… Address: ………………………………………..
    Date:
    Place: Signature/Left Thumb Impression of Declarant
    ……………………………………………………………………………………………………………………………………………………………………………………………………………………………….…
    ACKNOWLEDGEMENT
    We hereby acknowledge receipt of “Proposal-cum-Declaration Form” from Mr./Mrs./Ms. Holding Account No./Customer
    consenting and authorizing auto-debit from the specified Account No./Customer ID to join the Group Personal Accident Insurance Cover
    with “Universal Sompo General Insurance Co Ltd”, certifying coverage as per the Scheme, subject to correctness of information provided regarding
    eligibility and receipt of consideration amount.

    Date:
    Place: Seal and Signature of Authorised Bank Official

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