HEALTH DECLARATION FORM
(Pradhan
Mantri Suraksha Bima Yojana)
Customer Name
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Father/Husband Name
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Age
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Village
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Sex
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P.O
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P.S
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Dantan
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Dist
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Paschim Medinipur
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State
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West Bengal
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Pin
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Mob
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Applying For
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Pradhan
Mantri Suraksha Bima Yojana
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Health Condition
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My
health is in good condition.
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I HEREBY DECLARE and warrant the truth of the
foregoing particulars in every respect, and I agree that if I have made, or if
shall make false or untrue statement, suppression or concealment, then my
membership shall be canceled.
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Signature
of Applicant
Date:
Place:
BC Name
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Gourkrishna Chanda
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Customer Service Point
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Pundra
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Branch Name
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United Bank of India, Palsandapur
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