Claim Form

PRADHAN MANTRI SURAKSHA BIMA YOJANA (PMSBY) 20
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
(4) Day, date, and time of accident:

u/o22022
(5) Place of occurrence:
njuryon Hea
Acciden
(6)
(o) Nature ofaccident': Road
(7) Date of death: o 2

202
(8) Cause ofdeath/disability'(please specify): Read Ace iden &tnj Hend
9) Details of disability:
(10) Document attached as proof of permanent disability'/ death
(11) Aadhaar number'(Optional): 6 893 -So28 3 9

(12) Income-tax Permanent Account Number (PAN)' (Optional): DGiPs 5 3 64 A
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 claimantf legal heirs of the insured)
1. Name ofthe nominee: Semvaa Romilaben Sureshbha

2. Age of nominee: 36 y
3. In case the nominee is a minor, name ofthe appointee: NA
4. In case of no nomination or nominee pre-deceasing the insured member, name of the

claimant:
5. Proof of death° of nominee in case of nominee pre-deceasing the insured member:
6. Relationship ofthe nominee/claimant with the deceased: S Pouse
7. Contact mobile number: 0|2.13166o

8. Contact email address: Sen tas, To HP a SreaAd Aea
A
9. Contact address: Se nva Uas To motiPu
-
o. Sana ne, b
10. Details ofthe nominee/appointee/claimant (as the case may be):
() Particulars of bank account into which the claim amount is to be remitted: Unto
06 Inda
(a) Account number: 62g o 2o1 ooIS189
(b) Name of bank: Oniom ane ob I d ia
(c) Branch IFS Code:
Uet n o 562 993
(2) Aadhaar number
(Optional): S321 -
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
To be filled by the bank/Post officefrom enrolnment data or data ofbank/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): G29 g02o|00 DS 60T
On ion 8ank o6 ndq

2. Bank / post office name:
Sanand anch_
3. Branch name:
4. Branch IFS Code: OBIN OS6299&

Kanab ha
5. Name of father/husband of the member: Sueeghbha t s a a
6. Date of birth (as per the KYC document): "to o y o1(o

naktoana
7. Name of the insurer: Sureshbho Kanab ha
Senva Ramilaben suresLbha
8. Name of the nominee:
(SPoue
ate
Date of debit of premum from the bank/ post office account:
9
Date of remitting the premium into insurer's
2 S|oS|202
10. account:
It is certified that the above information is true as per PMSBY enrolment data and bank/
office records. post
Place: Sana nd
Date:
(Signature and seal of the authorised officiat 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 irom,

of
(name of the insurer) the sum of Rs. (Rs. One lakh in case permanent
death) only in rull
partial disability and Rs. two lakhs in case of permanent total disability
or
insurance in
and discharge of my claim under the said
and final settlement policy covering
respect of member Shri / Ms
(x) IAM
Signature of the witness
Name of witness:
Address: member/nominee/appointee/claimant
Signature of the insured

Date:
authorised official of the bank/ post office

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

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PRADHAN MANTRI SURAKSHA BIMA YOJANA (PMSBY) 20

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

(7) Date of death: o 2

(11) Aadhaar number'(Optional): 6 893 -So28 3 9

Part 2. Details of the nominee in case of death of insured member:

1. Name ofthe nominee: Semvaa Romilaben Sureshbha

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

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

6. Relationship ofthe nominee/claimant with the deceased: S Pouse

7. Contact mobile number: 0|2.13166o

To be filled by the bank/Post officefrom enrolnment data or data ofbank/post office

Part 3: Details in respect of the insured member

On ion 8ank o6 ndq

4. Branch IFS Code: OBIN OS6299&

6. Date of birth (as per the KYC document): "to o y o1(o

PRADHAN MANTRI SURAKSHA BIMA YOJANA

In consideration of approval of my claim referred above, I hereby accept irom,

Signature of the insured

authorised official of the bank/ post office

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