SyndSuraksha Form
ENROLLMENT FORM FOR SYND SURAKSHA
The Branch Manager
Syndicate Bank
Branch BIC
RO BIC
........................................................ Branch • Application No .
"(llronch terlal number)
Dear Sir,
Re: AppUcation form-cum-declaration of good health-cam-authorization for Group Insurance
Scheme ofLIC oflnd.ia for SavingJ Bank Account holden.
I ........................................................................................................................ ,having a Savings account
no. ...... ........ ........ ........ ........ ........ ........ ........ ........ ......... with your bank, hereby give my consent to
become a member ofLIC of India's Group Insurance Scheme for a basic sum assured of~(' 1,00,000/-and
additional accidental death cover of~ 1,00,000/-, which will be administered by SyndicateBankas Master
Policy Holder. My details are furnished as under:
Name(incapitals): Shri/Smt/Kum
Address
Phone: ................................ Mobile: ............................................... .
Savings Bank Account Number
Father/Husband's Name : Shri .............................................................................................. ..
Date ofBirth : ........................................ (DD!MMIYYYY), Age ...................... ..
Nominee's Name
Relationship with account holder
Date ofbirth ofNominee(ifminor)
Nameofappointee(forMinornominee): ..................................................................................................... ..
Relationship of appointee to Minor : ..................................................................................................... ..
Category Age Group Total Annual Premium
I 18-35 years t 165.00
II 36-45 years U35.00
ill 46-55 years ~ 585.00
IV 56-59 years f 875.00
I hereby authorize you to debit my Savings Account with your branch with ~ ..................................................... .
(Rupees ........................................................................................................ )towards initial proportionate premium
for enrolment as a member. I also authorize you to debit appropriate renewal premium depending on my age every year
to my above Savings Account with your branch on the annual renewal date or the previous working day if the renewal
date is a holiday. I undertake to maintain sufficient balance in my above SB account for debit of initial and subsequent
renewal premium amount
Though at present I am a member under the age group category- IIWIII, I also authorize you to debit the enhanced
premium as will be applicable to me, once I cross over to the age group under category-WilliiV at the rates then
prevailing.
I agree that I will be a member of the Scheme only in one branch of your Bank even though I hold accounts in other
branches of SyndicateBank and I am aware that my life cover shall be restricted to ~ 1,00,000/-(Rupees one 1akh only)
in the event of my death even iflhave joined as a member of this scheme in other branch ofSyndicate Bank.
I agree that my membership in the scheme will remain in force as long as all premiums due are paid and until I have
attained maximum age permissible under the scheme. You may continue to recover my premium as long as I am
eligible to remainamemberofthe scheme. I agree that in case I close my account with your Branch Office, I will cease
to be a member of this scheme from the immediately followingAnnualRenewal Date.
I agree that no liability will attach to SyndicateBank if for any reason your branch is not in a position to recover the
premium amount by debiting my account. Further, if the premium is not recovered by the bank for any reason
whatsoever no liability will attach to LIC ofindiaand no claim will be payable in such an instance.
I hereby declare that I am in sound health and am not suffering or suffered from any critical illness or any condition
requiring medical treatment for critical illness as on date. (The critical illness is defined as follows: The applicant
should not have suffered or to be suffering from AIDS, cancer, conditions requiring open chest surgery, history of
typical chest pain, kidney failure, brain stroke or paralysis or having undergone a major organ transplantation such as
heart, lung, liver or kidney. If the applicant had suffered from any of the above critical illness, he/she is not elig1ole to
join the scheme)
I agree to abide by the terms and conditions of the above Scheme and understand that Bank reserves the right to
discontinue or amend the terms of the scheme in future and any claim under the scheme is at the sole discretion of
LIC ofindiaandBankonly acts as a facilitator. I agree to your conveying the above particulars regarding my admission
into the group insurance scheme to LIC ofindia.
I hereby declare that the above statements are true in all respects and that I agree and declare that the above information
shall form the basis of admission to the above scheme and that if any information be found untrue, my membership to
the scheme, shall be treated as cancelled from my date of joining the scheme and all monies paid in respect thereof shall
stand forfeited.
Dated at········-································-·······-·· ... ··-··· on the ... - ....... - ........ day of ..... - ....... - ....... - ....... - ......... 20 ......... ..
Signature verified
(Authorized Signatory of the Braneh with seal) (Signature of the Applicant)
In eue of J olntAeeountHolden:
I/We . ......... ......... ......... ......... .......... 2) ...... ......... ......... ......... ......... ......... ......... .......... 3) ........................................ .
.................................................... holding account no ......... ................... with Mr.!Mrs ........................................ .
........................ ......... ................ have no objection to he/she joining the Group Insurance Scheme mentioned above and
agree that the premium may be debited from the account and further that the proceeds of the claim be paid to bislber
nominee/legal heir.
Name of the Joint Aeeount Holder Signatures
Not) ................................................................................ .
Nol) ................................................................................ .
No3) ................................................................................ .