Pradhan Mantri Jeevan Jyoti Bima Yojana - Claim Form: (To Be Completed by The Claimant & Bank)

Pradhan Mantri Jeevan Jyoti Bima Yojana – Claim Form
(to be completed by the Claimant & Bank)
1. Name of the Scheme: P r a d h a n M a n t r i J e e v a n J y o t i
B i m a Y o j a n a
2. Policy No.
3. Full Name and

Address of the Bank:
4. Name of The
Deceased Member:
5. District: State:
Pincode:
6. Pan Number of
Insured Member :
7. Bank Account No. of

Deceased Member:
8. Aadhar No. of
Deceased (if available):
9. Date of Entry Into D D M M Y Y Y Y

Scheme by Member
10. Date of Death of D D M M Y Y Y Y

Member:
11. Cause of Death:
12. Name of Nominee *:
13. Relationship of
Nominee:
14. Date of Birth of D D M M Y Y Y Y

Nominee:
15. Address of
The Nominee:
16. Mobile No. of the

Nominee:
17. Aadhar No. If Available:
18. Details of Savings IFSC Code:

Bank Account of
Nominee:
Savings Bank Account

No. :
SBI Life Insurance Company Limited: Registered and Corporate Office: Natraj, M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai- 400 069. Tel.: (022) 61910000.
Central Processing Center: 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector - 40, Seawoods, Nerul Node, Navi Mumbai- 400 706. Tel.: (022) 66456000.
IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 22 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in E-mail: info@sbilife.co.in
Page 1 of 2 PMJJBY/Ver 02/25-10-17
We hereby declare that the answers to all the above questions are true in every respect and this is the only claim preferred under the Pradhan
Mantri Jeevan Jyoti BimaYojana for the above deceased member. We enclose Death Certificate as the proof of death of the Member along with a
duly executed discharge form.
*In case the Nominee is a minor, the Guardian/Appointee may fill in the claim form.
(Signature of the Nominee* /Claimant)

We hereby certify that the above member was covered under the PMJJBY Scheme and premium was debited from his bank account on the
renewal date prior to his death and remitted to SBI Life Insurance Company Limited. We also certify that as per our records,
Shri/Smt. ____________________________________________________________ is the nominee of the above insured Member for the said
scheme. We further certify that the identity and bank account details of the nominee are checked and found correct.
Place: Date: D D M M Y Y Y Y
(Signature of authorized official of the Bank)

Encl.: Death Certificate & Discharge Receipt
Branch Name: Branch Code:
Email id: Contact Number:
DISCHARGE RECEIPT FOR PAYMENT UNDER PMJJBY SCHEME

Policy No:
Name of the Bank:
I/We, do hereby acknowledge receipt from SBI Life Insuranc e Company Limited , a sum of ` 2,00,000/- (Rupees Two lakhs only) in full satisfaction
and discharge of all our claim/s under the above policy on the life of Mr./Ms. ______________________________________ covered under this
scheme under Bank Account No. ________________________________________________________________.
Dated at _________________________this _______________________day of______________________20
Witness: __________________________________________ Revenue

Stamp
__________________________________________
__________________________________________

Details of nominee / appointee (in case nominee is minor):
Name:
Email id: Mobile No:
Aadhar Number
(if available):
Bank Account No.: Branch:
Name of the Bank:
Address :
IFSC Code:
{Copy of cancelled cheque to be attached ( if available)}/Copy of Bank Passbook/Statement giving bank account details.
*In case the Nominee is a minor, the Guardian/Appointee may fill in this form.
SBI Life Insurance Company Limited: Registered and Corporate Office: Natraj, M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai- 400 069. Tel.: (022) 61910000.
Central Processing Center: 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector - 40, Seawoods, Nerul Node, Navi Mumbai- 400 706. Tel.: (022) 66456000.
IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 22 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in E-mail: info@sbilife.co.in
Page 2 of 2 PMJJBY/Ver 02/25-10-17

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Pradhan Mantri Jeevan Jyoti Bima Yojana - Claim Form: (To Be Completed by The Claimant & Bank)

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Pradhan Mantri Jeevan Jyoti Bima Yojana – Claim Form

(to be completed by the Claimant & Bank)

1. Name of the Scheme: P r a d h a n M a n t r i J e e v a n J y o t i

3. Full Name and

7. Bank Account No. of

9. Date of Entry Into D D M M Y Y Y Y

10. Date of Death of D D M M Y Y Y Y

11. Cause of Death:

12. Name of Nominee *:

14. Date of Birth of D D M M Y Y Y Y

16. Mobile No. of the

17. Aadhar No. If Available:

18. Details of Savings IFSC Code:

Savings Bank Account

(Signature of the Nominee* /Claimant)

(Signature of authorized official of the Bank)

Email id: Contact Number:

DISCHARGE RECEIPT FOR PAYMENT UNDER PMJJBY SCHEME

Name of the Bank:

Dated at _________________________this _______________________day of______________________20

Witness: __________________________________________ Revenue

(Signature of the Nominee* /Claimant)

Email id: Mobile No:

Bank Account No.: Branch:

Name of the Bank:

(Signature of the Nominee* /Claimant)

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Dated at _____________this _day of____________20