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 following Sampurna Raksha Shield Card

In-Dependent Shield(Code-45,Card cost-₹7788/- all inclusive ) Individual Shield (Code-46, Card cost-₹11990/- all inclusive) Liability Shield - 25 Lakhs(Code-47, Card cost-₹17825/- all inclusive) Liability Shield - 50 Lakhs(Code-48, Card cost-₹23751/- all inclusive) Liability Shield - 1 Crore(Code-49 Card cost-₹31145/- all inclusive)) Customised Liability Shield (Code -49A, Card cost provided as per requirement)

I want to avail the following Add-On facility : (Available only after purchasing a Raksha Shield Card)

Individual Allergy Shield (Code- 50, Card cost -₹15000 = ₹17770 with GST) Family DEP Shield 1.0 (Code- 51A, Card cost- ₹5000 = ₹5900 with GST) Family DEP Shield 2.0 (Code- 51B, Card cost- ₹10000 = ₹11800 with GST) Family DEP Shield 3.0 (Code- 51C, Card cost- ₹15000 = ₹17700 with GST) Family DEP Shield 4.0 (Code- 51D, Card cost- ₹20000 = ₹23600 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- ₹30000 = ₹35400 with GST)

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)

Timestamp Camera for Android : Click here
Timestamp Camera for iOS : Click here

Select your image

I am uploading my PAN card

I am uploading my Aadhar Card

I am uploading a photo of my Bank Cheque

I am uploading the screenshot of my UPI payment page

Select UPI Screenshot

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)