APPLICATION FOR GROUP INSURANCE SCHEME FOR POWERLOOM WORKERS
(for Janashree Bima Yojana JBY)

Sir,

I, _________________________________________ after having read and understood the features, terms & conditions and the benefits of the Group Insurance Scheme (JBY), would like to become a member of the Scheme.

2) The particulars, in respect of my application, are as under :

1. Full Name :

2. Father's / Husband's Name :
3. Address :    i) Present postal address :
   Address :  ii) Permanent address :
4. Date of Birth :
5. Age :
6. Marks of identification :
7. State of Health :
8. Bank A/c. details, if any :

3) I hereby nominate the following person to whom the sum assured under the Scheme shall be paid in the event of my death while being covered by the above Scheme

4) I hereby declare that I am an economically poor powerloom worker and the income of my family falls Below the Poverty Line (BPL)/marginally Above Poverty Line.

5) I also hereby deposit Rs. 40/- (forty only), as my share of premium for becoming member under the Scheme.

6) I understand that this premium will insure me for a period of one year and I can renew, or, take policy next year & thereafter by paying Rs. 40/- p.a. before due date.

7) I hereby declare that all the particulars given above are true and correct to the best of my knowledge.

Eligibility	v	Powerloom workers living below and marginally above poverty line.
	v	Powerloom workers engaged in weaving, twisting, winding, warping and sizing.
	v	Weavers family owning 4 looms or less.
	v	Age between 18 to 59 years.
	v	Only one member per family (husband/wife and his/her spouse is considered as family)
Benefits	v	Natural death :		v	Rs. 20,000/- to the nominee
	v	Accidental benefits
			On death	v	Rs. 50,000/- to the nominee.
			Total permanent disability	v	Rs. 50,000/- to the beneficiary.
			Partial permanent disability	v	Rs. 25,000/- to the beneficiary.
Additional Benifits	v	Provision of a scholarship under Shiksha Sahayog Yojana.		v	Scholarship is allowed for 4 years.
	v	Rs. 300/- per quarter per child.		v	The beneficiary should remain member of the Scheme for getting the scholarship in subsequent year.
	v	Maximum of two childrens per member.		v	The student should not fail in the class.
	v	Students studying in IX to XII Std. are eligible
Premium	v	Rs. 200/- per annum total, of which Rs. 100/- from the social security fund of Govt. of India through LIC.
			Rs. 60/- by the Govt. of India through the Office of the Textile Commissioner
			Rs. 40/- by the member (powerloom worker).
Operational Modalities	v	Application-cum-Nomination Form to be filled by the member.		v	On receipt of full premium, LIC will issue a group policy.
	v	Submission of the completed form to the Nodal Agency/Authorized Agency (R.Os of the TxC. & PSCs)		v	The Nodal Agency will arrange to inform the members
	v	Submission of the completed form to the Nodal Agency/Authorized Agency (R.Os of the TxC. & PSCs)		v	The Nodal Agency will arrange to inform the members
	v	Declaration of Good Health to be furnished		v	In the event of non-payment of insurance premium by the member on next renewal date, the insurance cover will cease.
	v	The proof of age is to be satisfied by the Nodal Agency.		v	The member is free to rejoin the Scheme by payment of subsequent year's premium
	v	After verifying the application, the Nodal Agnecy will forward the list of members along with premium amount to concerned LIC, (P&GS) unit.
Claims Procedure	On Natural Death			On Accidental Death
	v	Claim Form to be filled by the beneficiary.		v	Claim Form along with Original Death Certificate, FIR, Police inquest report,Postmortem report & Police Conclusion report, to be submitted to the LIC through Noadl Agency.
	v	Claim form to be submitted to LIC along with death certificate through Nodal Agency.
	v	LIC will settle the claim by sending A/C. payee cheque to the beneficiary/nominee
				On disability
				v	Claim Form along with Original certificate of Medical Practitoner clarifying total / partial permanent disability is required to be submitted in case of disability due to accident to be submitted to LIC, P&GS Unit through Nodal Agency.