Application for Crop Insurance

PRADHAN MANTRI FASAL BIMA YOJANA (PMFBY) & WEATHER BASED CROP INSURANCE SCHEME (WBCIS) - PROPOSAL FORM

Name of the Insurance Company

Address

Proposal Form No.:

INSURANCE SCHEME: P.M.F.B.Y W.B.C.I.S

YEAR: SEASON: KHARIF RABI SUMMER

Details of crop(s) and area(s) proposed for Insurance

District: Taluk:

Hobli: Grama Panchayath: Village:

Survey No.: Name of crop: Type of Crop (Single / Mixed / Inter Crop):

Actual / Intended date of sowing: Area (Acre): Gunte / Cents #:

Loanee Farmer Non Loanee Farmer Saving A/c No.: Bank Name & Branch:

Proposer (Farmer) Name: Aadhaar No:

S/o, D/o, W/o, C/o: Other ID*: Other ID's No.:

Gender: Male Female Other Farmer Category: SF MF other

Caste: S.C. S.T. Other Date of Birth: Age in Years:

Address:

Pin code:

Mobile No: e-mail:

Documents to be attached

1. RTC Copy

2. Aadhaar Copy (If no Aadhaar, Submit other Identity card copy)

3. Bank passbook Xerox

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ACKNOWLEDGEMENT

Date: Year: 2016-17 Season: Kharif

Received Rs. (Rupees only) towards consideration as farmer's share of premium from Mr/Ms Son/Daughter/Wife of Mr/Ms for insuring below mentioned crop(s) and area(s) under PMFBY / WBCIS during Kharif 2016 season with reference to Proposal Form No. .

Area Insured District Taluk Hobli Gram Panchayat Crop Acre Guntas Farmer's premium (Rs.)

Declaration

1. I hereby declare that the provisions of the scheme have been read and understood by / explained to me in details in my own language before completing the Proposal Form including Farmer Registration Form. I hereby further declare that the particulars furnished above are true and correct. I have made disclosed all material facts. I have sown/ intend to sow the crop(s) proposed for insurance. Further, I undertake to inform the insurance company through Bank within the prescribed cut-off date, if there is a change in crop and pay any difference in premium which becomes payable.

2. I have not submitted / I will not submit any other crop insurance proposal covering the above mentioned crop grown on above survey number during the season under the scheme either through this bank branch / PACS or any Insurance intermediary or any other bank branch / PACS or any other scheme or with any other insurance company. I undertake to inform insurance company within 48 hours of occurrence of loss caused due to perils mentioned in the scheme in case of localized calamity/post-harvest losses. I undertake to assist insurance company and its losses assessors in every manner. I understand that payment of claim under prevented sowing will lead to cancellation of policy and no further claim will be paid.

3. I have submitted my valid Aadhar number or I certify that I have not enrolled for Aadhar and will enrol and get the Aadhar card within one month. (Strike whichever is not applicable)

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Notified area (as applicable)

Hobli Gram Panchayath Crop

Area insured Acre Gunte Sum insured (Rs.) Farmers Premium Rate (%) Farmer's Premium (Rs)

Details of remittance of premium

Payment Reference Number:

Payment Date:

Loan Amount-Rs.: Loan A/c No.:

Prohibition of Rebates

Section 41 of the Insurance Act provides as follows:

1. No person shall allow, or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect to any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebates except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.

2. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.

GUIDELINES FOR COMPLETION OF THE FORM

1. Only one proposal form to be filled up for all the crops proposed to be notified in a survey number.

2. Please complete the proposal form in all respects. The proposal should be duly signed by the proposer and all documents as mentioned above enclosed.

3. Insurance is a contract of Utmost Good Faith requiring the insured not only to disclose all material facts but also not to suppress any material facts. If you think any fact is material, please disclose it.

4. The insurance shall become voidable at the option of the insurer, in the event of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure of any material particular in the proposal form/personal statement, declaration and connected documents, or any material information having been withheld by the proposer or anyone acting on his behalf.

5. Kindly contact the Insurance company Office or its authorized Agents for any doubts or clarifications on the proposal form.

NOTE: The liability of the Insurance Company does not commence until his proposal has been accepted by the Insurance company and the premium is paid. The detailed terms and conditions are printed at the back of Acknowledgement.

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Terms and conditions

1. The coverage under PMFBY/WBCIS will be strictly as per operational guidelines framed by DAC & FW, GOI and the notification issued by the state government for the relevant season.

2. The Proposer shall submit only one proposal form for a season for the same piece of land.

3. The proposer shall disclose all material facts. Any discrepancy discovered later may lead to cancelation of insurance covered and forfeiture of premium. Material facts for this purpose will include but not restricted to facts relevant to crop insured, season insured, notified area insured and insurable interest.

4. The insurance company reserve the right to reject this proposal if it is not signed / not completely filled / required documents in support of insurable interest are not enclosed / full share of farmer’s premium is not paid.

5. The insurance cover may be cancelled if it is discovered at any time that: a. The farmer has insured more area than the land with insurable interest for him b. Has taken insurance on the same land in the survey number from different banks/ branches/ society or as loanee as well as non loanee farmer or has sown some other crops than notified / insured crop. In above cases the premium would not be refunded without prejudice to the right to investigate and make changes in the coverage accordingly at insured's risk, cost and consequences.

6. Proposer undertakes to inform the insurer in the event of any change in crop, extent of area sown, bank account and insurable interest within one week, otherwise point no.3 will follow.

7. Insurance company reserves the right to investigate ourselves or through others and reduce claim proportionately, if area insure is more than area sown.

8. Proposer undertakes to inform insurance company within 48 hours of occurrence of loss caused due to perils mentioned in the scheme in case of localized calamity/ post harvest losses.

9. Proposer undertakes to assist insurance company and its loss assessors in every manner.

10. Payment of claim under prevented sowing will lead to cancellation of policy and no further claim will be payable.

11. If required, at the time of claim, if any, the insured may be required to submit identity and address proof.

12. Proposer undertakes to submit discharge certificate / receipt before receipt of claim.

Place: Date: