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Application Form - GROUP CREDIT PROTECTION PLAN
(Group Scheme for Loan customers of SBFC Finance Limited)
Application No:
Leviosa Application No 4021060000335037
For Office Use Only
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Intermediary Details
Booking Account Code : Booking Account Name :
Partner RM Code : Partner Branch Code :
Customer ID :
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Proposer Details
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Gender:
Mr
M
Ms.
F
Mrs.
Name KRISHNA MURTHY GK
Address: 177A Devarahosalli Road, Near Govt Primary School, Yelekeri
Landmark: City: CHANNAPATTANA State: KARNATAKA
Marital Status:
Pincode: 562160 Date of Birth: 10011961 Single
Married
Landline: Mobile:
E-mail:
PAN No.: DJQPK5670A (Mandatory for premium above 49,999) Nationality: Indian
Mothers Maiden Name : Occupation:
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Nominee Details
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Name:
Date of Birth: Relationship with Proposer :
Appointee name :
Mr
Ms.
Mrs.
Appointees DOB: (Only where the Nominee is of Age 18 years or less)
In event of the death of the proposer any payment due under the policy shall become payable to the Nominee
proposed in this form. The receipt of the proceeds by the Nominee would be sufficient discharge to the Company.
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Policy Details
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Co-Pay :
Sum Insured : Yes Premium : Tenure: Months
No
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Details of the Person to be Insured (Including Proposer)
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Name Date of Birth Gender Height(cm) & Weight(kg) Relationship with
Proposer
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KRISHNA 10011961 SELF
MURTHY GK M
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Premium Payment Information
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Payment By : Cheque/Demand Draft/Card (Strike out
Cheque/Demand Draft No./Transaction ID :
whichever is not applicable)
Date:
Amount (`) : Premium Amount (`) :
Bank Name :
Sources of Funds :
Salary
Business
Others (if others, please specify)__________
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In case of payment through Cheque/Demand Draft, the instrument should be drawn in favour of Care Health
Insurance Company Ltd.
For Claims and Refund Process
I/We KRISHNA MURTHY GK do hereby authorize you to pay directly to SBFC Finance Limited towards
my outstanding dues against the loan borrowed vide loan account no. _____________________ from SBFC
Finance Limited out of the claim proceeds or premium refunds under Policy issued against application
No._____________________by Care Health Insurance Company Limited in my name.
Care Health Insurance Company Limited
Registered Office: 5th Floor, 19 Chawla House, Nehru Place, New Delhi-110019 Corresp. Office: Unit No.
604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram-122001 (Haryana) Website:
www.carehealthinsurance.com E-mail: customerfirst@carehealthinsurance.com Call us: 1800-102-4488 |
1860-500-4488 CIN: U66000DL2007PLC161503 UIN: IRDAI/HLT/RHI/P-H(G)/V.I/3/2017-18 IRDA
Registration No. - 148
Declaration
I hereby declare that all proposed members are in good health and entirely free from any mental or physical
impairments or deformities, disease/condition. Neither any of the proposed members have been hospitalized
for treatment of an illness or injury in past nor consulted any physician or conducted investigation for reasons
other than common cough, cold or flu. None of the proposed member are habitual consumer of alcohol,
tobacco, gutka or any recreational drugs.
Date:
Place:
Signature of the Proposer : _________________________________
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