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    Apgvb Insurance Consent Letter

    Uploaded by

    Mahesh Pasupuleti
    This document is a consent letter from a retired employee or family pensioner applying for inclusion in the group floater mediclaim insurance policy offered by the bank. The applicant provides their personal details like name, date of birth, gender, Aadhaar number and chooses an insurance coverage option between Rs. 3-4 lacs with or without outpatient department coverage. They authorize the bank to debit the applicable premium from their bank account. The applicant undertakes that the inclusion will be treated as withdrawn if the account has insufficient balance for premium deduction.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Apgvb Insurance Consent Letter

    Uploaded by

    Mahesh Pasupuleti
    67 views1 page
    This document is a consent letter from a retired employee or family pensioner applying for inclusion in the group floater mediclaim insurance policy offered by the bank. The applicant provides their personal details like name, date of birth, gender, Aadhaar number and chooses an insurance coverage option between Rs. 3-4 lacs with or without outpatient department coverage. They authorize the bank to debit the applicable premium from their bank account. The applicant undertakes that the inclusion will be treated as withdrawn if the account has insufficient balance for premium deduction.

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    apgvb insurance consent letter

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    This document is a consent letter from a retired employee or family pensioner applying for inclusion in the group floater mediclaim insurance policy offered by the bank. The applicant provides their personal details like name, date of birth, gender, Aadhaar number and chooses an insurance coverage option between Rs. 3-4 lacs with or without outpatient department coverage. They authorize the bank to debit the applicable premium from their bank account. The applicant undertakes that the inclusion will be treated as withdrawn if the account has insufficient balance for premium deduction.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    67 views1 page

    Apgvb Insurance Consent Letter

    Uploaded by

    Mahesh Pasupuleti
    This document is a consent letter from a retired employee or family pensioner applying for inclusion in the group floater mediclaim insurance policy offered by the bank. The applicant provides their personal details like name, date of birth, gender, Aadhaar number and chooses an insurance coverage option between Rs. 3-4 lacs with or without outpatient department coverage. They authorize the bank to debit the applicable premium from their bank account. The applicant undertakes that the inclusion will be treated as withdrawn if the account has insufficient balance for premium deduction.

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    © All Rights Reserved
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    Annexure-I

    Application / Consent Letter

    Medical Insurance Schemefor Retired Staff members /Family Pensioners


    GrOup floater Mediclaim policy-On Self-Fundingbasis
    S/o/D/oW/o_ D.O.B (As per Bank
    records). retired employee Family pensioner with the ID No/PPO No: wish to include in
    the Group floater Mediclaim Policy for Retired Staff members / family Pensioners, in terms of the
    Bank's Circular No: APGVB/Per & HRD/ 49 /2022-23 dated 11.10.2022.
    I wish to choose for coverage with the
    following option of sum assured.

    Sum Premium Tick ( ) at


    OPD Amount Option appropriate
    Assured
    (incl. GST) option
    4 lacs With OPD Rs. 33,295/- Option-1
    Without OPD Rs. 28,294/-
    Option-2
    3 lacs With OPD Rs. 24,972/-
    Option-3
    Without OPD Rs. 21,220/- Option-4
    Ifurnish below the details of myself and spouse (if applicable) for the purpose of coverage

    Staff member Details Spouse Details


    Name
    -
    Date of Birth
    Gender
    Aadhaar No.
    *(Scanned copies of the Self-attested Aadhaar Card to be attached)
    am a Retired Employee/Officer/ Family Pensioner from the Bank and
    I hereby authorize the
    Bank to debit the applicable premium of Rs. - (Rupees

    ) from my APGVB Account No:


    Maintained with our Branch:

    Iundertake that the inclusion cannot be made if there is


    insufficient balance in the account at the
    time of debit and I will treat this application as withdrawn by me
    voluntarily.
    Yours faithfully,

    Signature:
    Name
    PPO No:
    Mobile No
    Present Address:

    Please send scanned


    copy in pdf format to
    pensioncell@apgvbank.in witn subject "consent form for
    group mediclaim policy 2022

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