Indian Overseas Bank Retired Employees
Medical Assistance Scheme
APPLICATION FOR MEMBERSHIP- ONE TIME OPTION
PENSIONER/FAMILY PENSIONER/NON-PENSIONER/SPOUSE OF THE
NON-PENSIONER/SPOUSE OF THE DECEASED RETIRED EMPLOYEE

1. Name : ………………………………………………
2. Permanent Address : ………………………………………………
………………………………………………
………………………………………………
E-Mail :……………………………………………… Mobile No.……………………………….
3. Roll No. Designation & Name of : ……………………………………………….
the last attached Branch
4. Date of Birth : ……………………………………………….
5. Date of joining the Bank : ……………………………………………….
6. Date of retirement from Bank's service : ………………………………………………..
7. Nature of retirement : Superannuation/Voluntary Retirement/
VRS 2000 Scheme
8. Designation at the time of retirement : Officer - Scale VII/VI/V/IV/III/II/I
(Tick the appropriate Cadre)** Clerical/ sub staff/ PTS
9. Employment details, if any : Employed/Not employed
10. If employed the details thereof : ……………………………………………..
i) Name of employer : ……………………………………………..
ii) Monthly salary/wages : ……………………………………………..
11. Pension particulars : Pensioner/Non pensioner
Pension order No. and date :……………………………………..
Combined photograph of the
Applicant & spouse
12. Name of the branch & SB A/c No. :…………………………………….
where pension is drawn
13. Name of the branch identified for
drawing the benefits & SB A/c No. : …………………………………………….
(only in case of non-pensioner)
14. Full name of the spouse : ……………………………………………
Date of Birth : …………………………………
15. Employment details if any of the spouse : …………………………………………...
a) Name of employer : ……………………………………………
b) Monthly salary/wages : ……………………………………………
16. Amount of subscription***** : …………………………………………..
Details of remittance : …………………………………………..
DD No……………………………….. dated ……………. Drawn on CCO, Chennai.

DECLARATION

I declare that the above information submitted is true and correct to the best of my knowledge.I have read and understood the Indian Overseas Bank Retired Employees Medical Assistance Scheme and agree to abide by the terms and conditions mentioned therein.
Signature of the spouse Signature of the applicant
Date :
NOTE:
1. Delete whichever is not applicable.
2. In case of Family Pensioner and spouse of deceased non-pensioner details of the
deceased pensioner should be filled in the appropriate column.
3. **Please enclose a copy of salary slip/copy of Form 16 relating to the year of
retirement/PF statement/Any other document indicating the last cadre in which the
employee retired.
4. ****Subscription details – Officers Scale VII – Rs.26,000/- ; Scale VI – Rs.23,400/- ;
Scale V – Rs.20,200/- ;Scale IV – Rs.18,100/- ; Scale III – Rs.15,750/-;
Scale II – Rs.14,050/- ; Scale I – Rs.12,850/- ; Clerks – Rs.9,650/- ;
Sub-staff -Rs.5,675/- Part time sweepers – Rs.2,500/-
5. Application forms should reach PAD, Central Office on or before 30.09.2012