BRANCH NAME ACCOUNT NUMBER NAME OF THE A/C HOLDER DATE OF BIRTH Y EMAIL ID

BRANCH CODE DATE MOBILE NO GENDER 01

00/00/0000 NOMINEE NAME IS NOMINEE MINOR ? NOMINEE ADDRESS 5/6/2012 YES RELATION SHIP sriklanth

PACKAGE DESIGNED AND DEVELOPED BY HITHESH KUMAR.S STATE BANK OF INDIA MADIKERI BRANCH CELL:9035555969 EMAIL:hithesh.kumar@sbi.co.in

HEARTLY THANKS TO SRIKANTH K STATE BANK OF INDIA MADIKERI BRANCH Email: shrikanth.k@sbi.co.in

01 ## JANUARY 0JANUARY0

YOUR VALUED SUGGESTIONS FOR IMPROVEMENT OF THIS PACKAGE WILL BE ALWAYS WELCOME

###### / 0/01/0

01

01 02 03 04 05 06 YES 07 NO 08 09 MALE 10 FEMALE 11 12 FATHER 13 MOTHER 14 HUSBAND 15 WIFE 16 SON 17 DAUGHTER 18 SISTER 19 BROTHER 20 FATHER IN LAW 21 MOTHER IN LAW 22 DAUGHTER IN LAW23 UNCLE 24 AUNTY 25 FRIEND 26 27 28 29 30

01 02 03 04 05 06 07 08 09 10 11 12

JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER

1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978

2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

@gmail.com @yahoo.co.in

@yahoo.com @sbi.co.in @rediffmail.com @hotmail.com

31

1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Master Policy No: 137300-0000-00 GROUP PERSONAL ACCIDENT INSURANCE POLICY Proposal Form
CALL(Toll Free)

Sbi Sving Bank a/c No. Sbi Branch Name Name of the proposed insured person

0 0

1800221111/18001021111 CODE: 0 0 0 0 ## ## ## ## 0 0 ##

Address for this policy will be the same as provided by me to the State Bank of India for my saving Bank a/c citied above . Gender 0 Date of Birth

Email id Kindly Note

Mobile No 0

1) Coverage is for Accidental Death (AD) only 2) Period of insurance will be one year from the date of account debit transaction 3)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 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 Address of the Nominee/Guardian:0 0 0 0 0

Date :

0/01/0

Place :

0 Signature of the proposed insured

SECTON 471 OF INSURANCE ACT,1938

No 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 Corporate Registered Office: Natraj,101,201 &301, Junction of Western Express Highway & Andheri-Kurla Road, Andheri (East) Mumbai 400069

DEBIT AUTHORISATION ADVISE To, The Branch Manager State Bank of India 0 Dear Sir,

Pay-in -Slip No: From : Name Tel/Mob Date : 0 : 0 : 0/01/0

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 Date : : 0/01/0 0

Credit Amount Rs.100/-(Rupees One hundred only) to Power Jyothi A/c32226116717 (Premium Collection Account for SBI General Personal Accidental Insurance Policy).

Journal No

Bank Seal/ Stamp/ Signature

ACKNOWLEDGEMENT SLIP (Customer Copy)

Pay- In- Slip No State Bank of India Branch : Date : 0/01/0

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.

Journal No

Branch Seal/ Stamp/ Signature

Master Policy No: 137300-0000-00 GROUP PERSONAL ACCIDENT INSURANCE POLICY Proposal Form
CALL(Toll Free)

Sbi Sving Bank a/c No. Sbi Branch Name Name of the proposed insured person

1800221111/18001021111 CODE: ## ## ## ## 0

##

Address for this policy will be the same as provided by me to the State Bank of India for my saving Bank a/c citied above . Gender Date of Birth

Email id Kindly Note

Mobile No

1) Coverage is for Accidental Death (AD) only 2) Period of insurance will be one year from the date of account debit transaction 3)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 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 . Address of the Nominee/Guardian:.. .. ..

Date :

Place : Signature of the proposed insured

SECTON 471 OF INSURANCE ACT,1938

No 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 Corporate Registered Office: Natraj,101,201 &301, Junction of Western Express Highway & Andheri-Kurla Road, Andheri (East) Mumbai 400069

DEBIT AUTHORISATION ADVISE To, The Branch Manager State Bank of India

Pay-in -Slip No: From : Name 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).

Journal No

Bank Seal/ Stamp/ Signature

ACKNOWLEDGEMENT SLIP (Customer Copy)

Pay- In- Slip No State Bank of India Branch : Date :

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.

Journal No

Branch Seal/ Stamp/ Signature