Association Form

Master Name & Code

My name is : (As per Aadhar Card)

I am applying for the Level of

Suraksha Saathi Relationship Officer Sales Officer Location Manager Cluster Manager District Incharge State Incharge Vertical Head Vertical Chief Agency Partner Business Partner Connect Partner Disrtibution Partner

Kindly specify level (designation)

Kindly specify Zone

Kindly specify State

Kindly specify Area of Operation

Please fill the details of 5 prospective agents in the below format

Category

Level

Name

Mobile no

Category

Level

Name

Mobile no

Category

Level

Name

Mobile no

Category

Level

Name

Mobile no

Category

Level

Name

Mobile no

Please specify your T-Shirt size

S M L XL XXL XXXL

My Permanent Address is : (as per Aadhar Card)

My Correspondence Address is

My Primary Mobile number

My Alternative Contact Number

My preferred Email ID

My Date of Birth

My Bank Account Details (Account Number, Account type, Bank Name, Branch , Branch Address, IFSC Code)

My Cheque/Passbook Photo is attached

My Blood Group is

My Gender is

My Religion is

I am an Indian National

My Nominee Details (Name, DOB, Relation, Contact Number, Email ID)

My Highest Education Qualification is

My Educational Documents are attached

Upload up to 10 supported files. Max 10 MB per file.

I confirm that I am NOT Employed Full Time in any other organisation

The details of the last job held by me (Please specify organisation name, role, worked from - to, salary drawn)

I have the following certifications

AMFI IRDAI NISM RERA Other (Specify below)

Other

My PAN Photo is attached

My Aadhar Photo is attached

My Selfie is attached

I will provide complete details of my immediate Family Members while completing the joining formalities

Yes

I will provide complete details of my all my Educational Qualifications while completing the joining formalities

Yes

I will proide my complete Employment Declaration during completing the joining Formalities

Yes

I am aware that it is expected that within 3 months of the date of joining, will generate at least 3X business month on month ,in proportion to my monthly salary. Failing which, I might be terminated.

Yes

I have thoroughly read and understood all the policies, terms & conditions made by the company

Yes

Shield Application Form

Select Date

Associate/Distributor Name & Code

My Referrer Name & Code

Subscriber Full Name (as per Aadhar Card)

I want to apply for

In-Dependent Shield(Code-45,Card cost-₹6100+₹100 Membership= ₹7316 with GST ) Individual Shield (Code-46, Card cost-₹7100+₹100 Membership= ₹8496 with GST) Individual Shield Code-46A, 2 years card cost with discount +Membership= ₹12971 with GST) Liability Shield - 25 Lakhs(Code-47, Card cost-₹8100+₹100 Membership= ₹9676 wit h GST) Liability Shield - 50 Lakhs(Code-48, Card cost-₹9100+₹100 Membership= ₹10856 with GST) Liability Shield - 1 Crore(Code-49 Card cost-₹10100+₹100 Membership= ₹12036 with GST)) Customised Liability Shield (Code -49A, Card cost provided as per requirement) I want to apply for addon product Individual Allergy Shield (Code- 50, Card cost -₹12000 = ₹14160 with GST) Family DEP Shield 1.0 (Code- 51A, Card cost- ₹3000 = ₹3540 with GST) Family DEP Shield 2.0 (Code- 51B, Card cost- ₹6000 = ₹7080 with GST) Family DEP Shield 3.0 (Code- 51C, Card cost- ₹9000 = ₹10620 with GST) Family DEP Shield 4.0 (Code- 51D, Card cost- ₹12000 = ₹14160 with GST) Criti-Shield 1.0 (Code- 52A, Card cost- ₹5000 = ₹5900 with GST) Criti-Shield 2.0 (Code- 52B, Card cost- ₹10000 = ₹11800 with GST) Criti-Shield 3.0 (Code- 52C, Card cost- ₹15000 = ₹17700 with GST) Criti-Shield 4.0 (Code- 52D, Card cost- ₹20000 = ₹23600 with GST) Criti-Shield 5.0 (Code- 52E, Card cost- ₹25000 = ₹29500 with GST) Other (Please Specify Below)

Other

Applicant Full Address(include district, state & Pin code)

Applicant Date of Birth

Applicant Contact number

Applicant Email ID

Applicant Bank Details (Account Number, Account type, Bank Name, Branch Name, Branch Address, IFSC Code)

Nominee Name (Only Nominate person above 18 years of age)

Nominee Date of Birth

Nominee relation with Applicant

Spouse Child Parent Brother Sister Other relative(please write relation in bracket beside nominee name)

Nominee Contact Number

Nominee Email ID

I accept the non-refundable service charge as per services with membership charge Rs.100/- with advisory fees as per slab by BCS/BIJOCAP FINVEST/BFPL

Do you require a printed PVC card in addition to the E-Card, if yes, there is an additional charge of Rs.100+GST (Total Rs.118)

Yes No

Application Agreement

The process / login / service fees deduction as per set slab imposed by company will be acceptable to me.
The annual membership fees deduction for listed service imposed by company will be acceptable to me.
I am fully agreed and accepting that, card will be delivered in 15 days of registration.
I am fully agreeing and accepting that I will submit all standard and required documents to the company.
I am fully agreeing and accepting the non-refundable service that is provided by the company .
I am fully agreeing and accepting to take liability cover for security purpose of my liabilities offered by company.
I am fully agreeing and accepting that the SHIELD service is non-transferable.
I am fully agreeing and accepting the stationery charges set by company at the time of application if I opt for the same.
I have thoroughly read and understood all the policies, terms & conditions made by the company for applicant / user.

Yes, I accept the agreement

I agree to provide details of 2 references, who might be contacted by the company in regards to Suraksha Shield. Please provide the details as per below format,

Name of perosn 1

Mobile no of person 1

Name of perosn 2

Mobile no of person 2

I am uploading my selfie(one with eyes open & one with eyes closed) OR I am uploading my photo captured though timestamp camera(app available on play store, see picture below)