Annexure II

Medical Insurance Proposal Form For the use of Retired Employees only.
Period: From 01/04/2015 To 31/03/2016
All the fields marked with (*) are mandatory.
For queries call: Anand Rathi Insurance Brokers Ltd.
(033-40020000 Ext No. 251,256,254)

Fill up the form in BLOCK LETTERS

*Sum Insured opting for _________ Lacs (1.5/2.0/2.5/3.0/4.0/5.0
Lacs)
Name of Retired Employee*:
Date of
Retirement*:

N.B. : Proportionate premium from May 2015 onwards as

noted in table below is applicable only for the employees
retiring from April 2015 onwards

Pension Drawing From*(Branch Name):

Branch from which delivery of Mediclaim Card is to be made :

Is this the 1st time you are taking this policy or it is a continuation?*
( Tick the correct option)
S.P.F. No.*:

1st Time/Continuation

P.P.O. No.:

(If Any)

Address* (For Correspondence) - Kindly fill up the address properly to help us contact you if required.
Is the mentioned address same as last year?
Yes / No
(Tick the correct option)
House No. & Street Name*:
Landmark*:
Post Office*:

Police Station*:

City*:

Pin Code*:

Any additional information regarding the address:

Tel. No. (with STD Code):

Mobile No.*:

Email ID (To help us reach you better)*:

Pension A/c No.(13 digit No.)*:

IFSC Code* (Mandatory):

Mode of Retirement*: Superannuation/Voluntary Retirement under Service/Pension Regulations/Under VRS

Details of Members Covered* (Retired Employee + Spouse) / (Spouse of deceased employee)

Name on Members*

Date of Birth*

Age

Sex (M/F)

Sum Insured
(Tick)

Retd. Emp.

1.5/2.0/2.5/3.0/
4.0/5.0Lac
Wife/Husband
Nomination : I, Mr./Mrs./Ms.________________________________________, a retired employee/spouse of the deceased employee
of the Bank do hereby assign the money payable by "National Insurance Co. Ltd." in case of my death to Mr./Mrs./Ms.
______________________ Relation____________ and further declare that his/her receipt shall be sufficient discharge of the company.
Place:
Date:

Signature of Retired Employee / Spouse of Deceased Employee

For U.B.I. Branch Use Only (Kindly follow the premium chart for the correct amount of premium)

Coverage
Rs.1.50 lac
Rs.2.00 lac
Rs.2.50 lac
Rs.3.00 lac
Rs.4.00 lac
Rs.5.00 lac

April15 May15 June15July15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16
1957
3562
5702
7841
8912
9982

1794
3265
5227
7188
8169
9150

1631
2968
4752
6534
7427
8318

1468
2672
4277
5881
6684
7487

1305
2375
3801
5227
5941
6655

1142
2078
3326
4574
5199
5823

979
1781
2851
3921
4456
4991

815
1484
2376
3267
3713
4159

652
1187
1901
2614
2971
3327

489
891
1426
1960
2228
2496

326
594
950
1307
1485
1664

Certified that Shri./Smt.___________________________________, (SPF No. ___________) is a retired employee/spouse of the

deceased employee of the Bank and he/she remitted the premium as per the following details:
Transaction No.
United Bank of India
Name of Forwarding Branch:

Date:

Amount:

Place:
Date:
_________________________________________Signature of UBI Branch Manager with Seal
**This form duly complete in all respects may be sent by the Branch in duplicate to: The Chief Manager, Disciplinary & Industrial Relation Division,
United Bank of India, Head Office, 13th Floor, 11, Hemanta Basu Sarani, Kolkata-700001 (Tel. No. 033-2248-2935)

163
297
475
653
743
832