APPLICATION - 2

APPLICATION FOR GROUP INSURANCE SCHEME FOR POWERLOOM WORKERS
[for Add-on-Group Insurance Scheme (Add-on-GIS)]

To,
The Officer-In-Charge
Regional Office/Powerloom Service Centre of the
Office of the Textile Commissioner,
Govt. of India.
__________________
for Office use
  1. Regn. No.:     
  2. Date of Regn: 

  Signature & Seal of the Officer  
Sir,
 
       I, _____________________________ after having read and understood the features, terms & conditions and the benefits of the Group Insurance Scheme (Add-on-GIS), 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 :
    1. Present postal address:

    2. Permanent address:

  4. Date of Birth:
  5. Age:
  6. Marks of Identification:


  7. State of Health:
  8. Bank A/c. details, if any:
A/c.No. Name & Address of the Bank Whether joint/single
     
 
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.

 Name   Age   Relation-
ship 		  Address   Signature/thumb
impression of
Nominee		  Bank A/c details
(Name of the
Bank / Branch /
A/c No.), if any
           
 
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. 90/- (ninety 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. 90/- p.a. before due date.
 
7)    I hereby declare that all the particulars given are true and correct to the best of my knowledge.
 
Place: _____________ __________________
Date:  _____________ Signature of Member
"---------------------------------------------------------------------------------------------------------------------
 
RECEIPT/ACKNOWLEDGEMENT
GIS FOR POWERLOOM WORKERS (Add-on-GIS)


    This is to acknowledge the receipt of application form along with Rs. 90/- (ninety only) from
Shri/Smt. ______________________________ S/o/W/oShri/Smt. ______________________________ resident of ___________________________________________________ for becoming a member under Add-on-GIS, on _____________ (date) and assigned registration No. ____________ dated ___________
 
 
 
Place: _____________ (Signature & Seal)
Date:  _____________ Officer-In-Charge
 
 
 
Salient features of the scheme
       The Scheme is operated by the Government of India in the Ministry of Textiles, through the Textile Commissioner (TxC), jointly with the Life Insurance Corporation of India. The Salient features of the Scheme are given below:

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    On account of Natural/Accidental death -- Rs. 30,000/- to the nominee
 
Premium    v  Rs. 180/- per annum total, of which
       F     Rs. 90/- by the Govt. of India through the Office of TxC.
       F     Rs. 90/- by the member (powerloom worker).

Operational
Modalities		    v  Application-cum-Nomination
        Form to be filled by the member.
   v  Submission of the completed
        form to the Nodal Agency/
        Authorized Agency (Offices of
        TxC)
   v  Declaration of Good Health to be
        furnished.
   v  The Proof of age is to be satisfied         by the Nodal Agency.
   v  After verifying the application,
        the Nodal Agency will forward the         list of members along with
        premium amount to the
        concerned LIC (P&GS) unit.
  		   v  On receipt of full premium, LIC
        will issue a group policy
   v  The Nodal Agency will arrange to
        inform the members about the
        coverage.
   v  In the event of non-payment of
        insurance premium by the
        member on next renewal date,
        the insurance cover will cease.
   v  The member is free to rejoin the
        Scheme by payment of
        subsequent year's premium.
Claims
Procedure		    v  On natural/accidental death claim form to be filed by the beneficiary
   v  Claim form to be submitted to LIC along with death certificate through         Nodal Agency/Authorized Agency
   v  The claim forms duly verified and certified along with necessary         document shall be submitted to LIC, P&GS Unit through the concerned         Nodal Agency.
   v  LIC will settle the claim by sending A/C. payee cheque to the         beneficiary/nominee.