Sbi Card Application Form

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Approve

WCP Application No.

Reject

PHOTO

Please fill in the form in BLOCK LETTER and attach all relevant documents. Please complete all sections. Tick

in boxes if applicable or

if not applicable.

FOR OFFICIAL USE ONLY

Lead Reference No.

SE/TC Code

Doc Executive Code

Fee Code

Br. Emp. Name: ______________________ Br. Emp. Mobile:

BRE Code: _________________________

BM Name: __________________________ BM PF No:

Bank Employee PF Index No.

Branch Code Source Code

CSM Code

SBI Signature Card

SBI Platinum Card

SBI Gold & More Card

I want to apply for (please tick only one)

I. MY PERSONAL DETAILS

My Name

PAN No.

-

(Please leave space between STD code and the Tel. No.)

-

(Please leave space between STD code and the Tel. No.)

E-mail ID*

(Your monthly SBI Card statement will be delivered to the above E-mail ID)

-

(Please leave space between STD code and the Tel. No.)

My Residence is

My Vehicle

II. MY EMPLOYMENT DETAILS

I am

My Designation

My Department

My Industry / Business

IT

Banking & Finance

Government Service

Consulting

Telecom

BPO/KPO

Name of my company / firm

-

(Please leave space between STD code and the Tel. No.)

Extn.

-

Extn.

(Please leave space between STD code and the Tel. No.)

*In case you require a physical statement, please select delivery address

Residence

Office

(Default delivery option will be E-mail ID)

FAMILY HEALTH FLOATER – ENROLLMENT FORM

I authorise you to charge my SBI Card with the premium applicable as per my family size, plan and period of insurance opted plus processing fee (as indicated as overleaf).

Declaration:

I declare that persons proposed are my family members and that they are not engaged in high-risk occupations. I also declare that none of them suffer from any pre-existing conditions and that I

Details

Name

Date of Birth

Relation

Gender Any existing

Suffering Since

have given explicit information of such instances of diseases and understand that such pre-existing conditions will not be covered under the policy. All information given in this form on behalf of family members

and myself is correct and true to the best of my knowledge and belief. I consent to the insurers to seek information from any hospital. This proposal shall form the basis of the contract of insurance. I agree that the

(DD/MM/YYY)

M/F

illness

(MM/YYYY)

insurance benefit available to me as a cardmember shall become voidable by Royal Sundaram Alliance Insurance Company Limited in the event of any untrue or incorrect statement or misrepresentation or

nondisclosure of any particulars in this form or in the event of withholding any material information to obtain the insurance benefit. I also agree to provide photographs of all persons enrolled in the prescribed form.

Adult 1

I hereby agree to enroll myself and/or my dependants to SBI Card Family Health Floater. I authorize M/s Medicare TPA Services Ltd., to process claim and receive reimbursement proceeds from Royal Sundaram

Alliance Insurance Company Limited. I authorize Royal Sundaram to debit my SBI credit card towards payment of premium for Family Health Floater Plan. I understand that the policy would be issued to me subject

to the approval of my application for SBI Card.

Adult 2

Please tick if you want the Flexipay facility on the premium amount.

(“Flexipay, the convenient, affordable and easy-to-pay monthly instalment plan. At a low rate of interest.”)

Child 1

Renewal Facility:

(Please tick this if you want to opt for hassle free renewal year after year)

Yes, if my proposal is accepted by Royal Sundaram, I would like the policy to be renewed every time it is due for renewal provided, I am eligible for the same

and my SBI card is valid.

Child 2

Please sign here only if you are

Proposer can consider undermentioned relationship for declaring as Adult : Self, Spouse, Father, Mother

opting for Family Health Floater

Occupation

____________

Nominee Name

_____________________________

Relationship

____________

SBICPSL is the corporate agent for Royal Sundaram Alliance insurance Co. Ltd. Vide Corp. Agency License No. 2105154