Corporate Office:

IFFCO-Tokio General Insurance Co.Ltd.

IFFCO Tower, Plot No – 3,
Sector - 29, Gurugram (Haryana) – 122001
Website - www.iffcotokio.co.in
Call Center – 1800 – 103 – 5499 (Toll free)
Or 0124- 4285499

PRADHAN MANTRI FASAL BIMA YOJNA (PMFBY)

INTIMATION-CUM-CLAIM FORM
1.Details of Insured Farmer
Sr. No Farmer Name Father/Spouse Name Telephone/Mobile No. Email ID Aadhar Card
Number

2.Communication Address of Farmer

State: District: Tehsil: Block:

Nyay Panchayat/ Revenue Circle: Gram Panchayat: Village: Pin Code:

3. Particular of Crop Insurance: If insured through a bank

Sr. No Season Year Loanee Bank Account No. Bank and Kisan Credit Card Premium Date of Premium
or Branch Name (KCC) Amount deduction/
Non-Loanee (INR) Receipt
(Please mention)

4.Particular of Crop Insurance: If Insured through other Channels (Intermediary/Direct)

Sr. No Name of Intermediary/Direct) Farmer ID/ Proposal No./Cover Note No.

5.Particulars of Cause of Crop loss and Date of occurrence

Cause of loss (Tick as appropriate) (√) Date of Crop Loss

Crop losses due to Localized calamity viz. Landslide/Hailstorm/Inundation

Date of Harvest
Post-Harvest lossess due to Cyclone /Cyclonic Rains/ Unseasonal Rains

6.Particulars of Insured Crop

Sr. No Khasra Crop Date of Irrigated or Sown Area Insured Approximate Approximate
Number/ Sowing unirrigated (ha) Area(ha) affected Area Crop loss in
Chak (Please mention (ha) affected Area
Number appropriate) (%)

7.Details of other Crop Insurance

Sr.No. If insured from other insurance company against Insurance Company Policy Number Sum Insured Area Insured
the same insured crop. (INR) (ha)
Yes/No, please provide details
 Declaration

I……………………………………. being insured under PMFBY do hereby declare and set forth that at or about………………O’clock
a.m./p.m. dated …………………. (above ticked incidence) was occurred in the above-mentioned farm due to which insured
………………………. crop has been damaged. I, further assure you that I will not remove any part of crop from the affected farm
or in any way change appearance of crop in the affected farm till survey work is completed. Please arrange to survey my farms.
I am herewith enclosing the proof of ownership of land record/tenancy/sharecropper agreement and copy of Cover
note/premium receipt as applicable with this claim form. Insurance company can take any legal action against me if found to
damage the crop and claim for crop loss.

Date: Signature/Thumb Impression of farmer

For Bank/ Intermediary

This is to certify that above-mentioned particulars of crop insurance are correct as per our records and premium thereof has
already been sent IFFCO-Tokio General Insurance Co. Ltd as per the relevant Notification.

Date: Signature of Authorized signatory of issuing

Bank/Intermediary with Seal, (Name and Designation)

Note:
Please intimate within 72 Hour of crop loss to IFFCO Tokio’s toll free number 1800-103-5499.