APPLICATION FORM FOR ENROLMENT/ RENEWAL OF PSB MEDICLAIM INSURANCE SCHEME FOR RETIRED EMPLOYEES/OFFICERS
The AGM Punjab & Sind Bank Employees Welfare Fund Trust Sidhartha Enclave, Ashram Chowk New Delhi-110014 Dear Sir,
Affix latest photo of Self
Please enrol me as Member/Renew my membership for the PSB Mediclaim Scheme. I agree to abide by the rules & regulations of the Mediclaim Policy as may be modified/ amended from time to time. Particulars about myself & my spouse are given below: 1. Name of Ex-employee :
2. Father’s /Husband Name :
3. PF CODE :
4. Name of Spouse : 5.Date
of
Birth
(a)Self
:
6. Date of Retirement :
7. Office [BO/ZO/HO Deptt.] From which Retired: (a) Name :
(b) Code :
8. Name of Pension Paying Branch :
Code of Pension Paying Branch : 9. Designation at the time of Relinquishing service :
10. Present Address :
Pin Code
:
(b)Spouse:
Affix latest photo of Spouse
11. Permanent Address
:
:
Pin Code
Mobile No :
12. Telephone No with STD code:
13. E-Mail ID : 14. Type of retirement eligible for membership: (i) Superannuation (ii) Medical Ground (iii) Compulsorily retired (iv) voluntarily retired Scheme 2000 (v) Voluntarily retired under pension Regulations (other than superannuation,the eligibility criteria is 30 years of service or 55 years of age at the time of demiting office (vi) Any other (attach documentary proof) 15. I Hereby authorise
you to debit an amount of Rs.500- (Rupees Five Hundred only) from my C.B.S A/C
No.
towards enrollment fee/Renewal Fee for the membership
of Punjab and Sind Bank Employees Welfare Fund Trust. I undertake to keep sufficient balance in the A/C. I understand that I shall be entitled for the Floater Group Mediclaim Policy only after the fee is debited to my A/C. 16. Declaration: i. I agree to abide by the terms & conditions of the Mediclaim Scheme. ii. The information given above is true to the best of my knowledge iii. I also undertake that if at any point of time, during the currency of my membership of the scheme, the information submitted by me, either in relation to application form or Hospitalization claim, is found to be false/misleading, my membership to the scheme can be terminated without any notice to me. The amount deposited by me towards my subscription of scheme will stand forfeited & I will not be eligible to become member of the scheme again. iv. I will inform any change of my address to the Bank immediately by Registered Post. v. I understand that the application form entitles me to coverage under the Floater Group Mediclaim Policy with effect from the date of application/ payment of premium to subsequent 10th May (the date of expiry of the Group Insurance Policy) and to avail continuity of Mediclaim Policy facility, I undertake to resubmit the form every year again before the expiry of the policy. In case of non submission of form in time the Mediclaim facility shall start from the date when the renewal form is received at HO PF Department and premium remitted to Insurance Company.
Place
Place………………………
………………………………… Signature/T.I of retired employee
…………………………………… Signature/T.I. of Spouse
Date: Date …………………….. Certified that Sh. /Ms. ………………………………………………………………………………………., is drawing pension from our Branch Holding……………….…………. Account with us. WE HAVE VERIFIED THE CORRECTNESS OF C.B.S A/C NUMBER OF THE ABOVENAMED EX-EMPLOYEE.
Signature of Branch Incharge under Seal -------------------------------------------------------------------------------------------------------------------------NOTE: 1. Application form is complete in all respects, must be sent to HO directly. 2. Strike Off whichever is not applicable. 3. Please ensure to write your Pin Code.