Claim Form
Claim Form
Claim Form
CLAIM-CUM-DISCHARGE FORM
(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 appointee1, 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:
2. Age of nominee:
9. Contact address:
10. Details of the nominee/appointee/claimant (as the case may be):
(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 accident5 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/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) 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 / Post office from enrolment data or data of bank/ post office
1. Bank / post office account number (as per bank’s CBS/ post office records):
3. Branch name:
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 authorised official of the bank/post office)
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
(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/Talukdar, 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.
7 This information 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.