Account Opening Form

For Individuals

481-Ver 1.1-March 2014 DCB Bank Limited M026 / Dec 17 / 2.1

 Indicative List of Documents that can be provided to open a Bank Account
Description of Document Can be obtained for
Identity Address

Normal

PAN Card Passport

Passport Voter's Id issued by Election Commission of India

Voter's Id issued by Election Commission of India Driving License

Driving Licence
Letter issued by Unique Identification Authority of India (UIDAI) containing details of
name , address and Aadhaar number or any other document as notified by the
Central Government in consultation with Reserve Bank of India (RBI) or ‘Aadhaar’
Letter or ‘Aadhaar Card
Job card issued byunder National Rural Employment Guarantee Act (NREGA) duly
signed by officialer of the State Government
Letter issued by Unique Identification Authority of India (UIDAI) containing details of
name , address and Aadhaar number or any other document as notified by the
Central Government in consultation with Reserve Bank of India (RBI) or ‘Aadhaar’
Letter or ‘Aadhaar Card’
Job card issued byunder National Rural Employment Guarantee Act (NREGA) duly
signed by officialer of the State Government

Simplified (for low risk customers)

Identity card with applicant's photograph issued by Central/ State Government Address card issued by India Post
Departments, Statutory / Regulatory, Public Sector Undertakings, Scheduled
Commercial Banks and Public Financial Institutions (Document Code - 01) Letter from Block Development Officer / Revenue Official

Letter issued by a gazetted officer with a duly attested photograph of the person.
(Document Code - 02)
*Senior Citizen Card issued by any State Government
Letter with attested photograph issued by recognized public authority such as
Collector / Tehsildar / Magistrate
Legal Guardianship Certificate issued by the Local Level Committees set up under
the National Trust for the Welfare of Persons with Autism, Cerebral Palsy, Mental
Retardation and Mental Disabilities Act, 1999 and under the Mental Act, 1887
appointing Legal Guardians for persons with disability can be accepted to open an
account (for accounts of people with disability)
Passbook with attested photograph from any Scheduled Commercial Bank with
latest completed 3 months account statement
Letter from Block Development Officer/ Revenue Official
Letter from Scheduled Bank as per Annexure K
Letter from Sscheduled Bbank as per Annexure K
Social security card issued by State Government
Certificate issued by Gram Panchayat
Declaration from joint holder to consider the address as proof of address along
with proof of relationship
Property or Municipal tax receipt (not more than one year old)*
(Document Code - 02)
Utility bill which is not more than two months old of any service provider (electricity,
telephone, postpaid mobile phone, piped gas, water)* (Document Code - 01)
Letter of allotment of accommodation from employer issued by State or Central
Government departments, statutory or regulatory bodies, public sector
undertakings, scheduled commercial banks, financial institutions and listed
companies. Leave and license agreements with such employers allotting official
accommodation can also be obtained. (Document Code - 05)

Social security card issued by State Govt. Documents issued by Government departments of foreign jurisdictions and letter
issued by Foreign Embassy or Mission in India. (Document Code - 06)
Certificate issued by Gram Panchayat

Small

Photograph, Signature & Self Certification Photograph, Signature & Self Certification

Please Note:
1. Customer must sign the Account Opening Form (AOF) in the presence of Bank officials
2. The cheque provided as the initial Account Opening Amount (AOA) must be signed by the prospective customer and this signature should match with the signature on the AOF.

One Time Password (OTP) based e-KYC

(Please note that the customer cannot hold more than one OTP based e-KYC account.

Instruction for filling Account Opening Form

A
CB
Please fill the form preferably in ‘BLACK’ ink only Please use in CAPITAL LETTERS only

Hint boxes give tips and highlight important points across the form Please tick the appropriate boxes

Please write your NAME as it appears in all your support documents Specify the addresses along with City, State and PIN Code

Please countersign in full for any overwriting / alteration ALL PHOTOCOPIES of documents to be SELF-ATTESTED by the applicant
 Bank Use only (* Fields are Mandatory) Application No.: IND

Customer ID:

Account No.:

*Occupation Code: Applicant 1: Joint Applicant 1: Please specify the occupation code as mentioned by customer in the form.

Joint Applicant 2: *Segment Code RM / CSE / RO / CBE (Code):

Branch: SOL Code: Date: D D M M Y Y Y Y

Funding: Txn. / ID No.: Date: D D M M Y Y Y Y Value Date: D D M M Y Y Y Y

Relationship Form
“I / We hereby apply for a relationship with your Bank under which I / we wish to open an account.”

Savings
Classic Shubh-Labh BSBDA Privilege Elite Corporate Payroll (Basic) Corporate Payroll (Plus)

Suraksha Others (please specify

Fixed Deposit Cash Back Shaurya Saahas
Fixed Deposit including Personal Current A/c.)

Personal Details: Primary Applicant (* Fields are Mandatory)

Simplified (for low OTP based e-KYC
*Account Type: Normal risk customers) Small Number:
e-KYC
*Name: Mr. Mrs. Ms. Dr. Prof. Capt. Others Existing Customer ID:
(If applicable)
Maximum
32 characters.
(First Name) (Middle Name) (Last Name)
Maximum
*Short Name: 19 characters.
This name
would
*Status: Minor Sr. Citizen Pensioner Other General Staff, if yes, Employee No. appear on the
Debit Card
*Date of Birth: D D M M Y Y Y Y *Gender: Male Female Third Gender

*Nationality: Indian Other (pl. specify) Marital Status: Single Married

Please fill
FATCA
*Country of Birth: *Place of Birth: Declaration
Form if you are
U.S.A. or other
*Citizenship: *Residence for Tax Purposes: country citizen
/ resident
U.S. Person: Yes No Category: General MBC OBC SC ST Others

Religion: Hindu Muslim Christian Sikh Buddhist Jain Parsi Others

*Mother’s Full Name:

*Father / Spouse Full Name:

*Mother’s Maiden Name:

*Residential Status: Resident Individual Non Resident Indian Foreign National Person of Indian Origin
Type of card
*Card: Debit Card required Yes No International Debit Card required Yes No Rupay Yes No would be
based upon
Type of card & cheque book issuance would be based the product
ATM Card required Yes No Visa Yes No
upon the product.

*Permanent Account Number (PAN): Form 60 If PAN is

not available
please fill in
*Aadhaar Number: Your unique identification number Form 60

Passport Number: Expiry Date: D D M M Y Y Y Y

Required if
Passport or
Driving Licence: Expiry Date: D D M M Y Y Y Y Driving licence
provide as
Voter Identity Card: Identity /
Address proof

NREGA Job Card:

Others:
(any document notified by Identification Number:
the central government)

*Proof of Address: Passport Driving Licence UID (Aadhaar) Voter Identity Card Simplified Measures Account
Document Type Code

NREGA Job Card Others

Communication Address:

City: PIN:

*Landmark:
3
State: Country: All alerts will be
sent to the
Telephone: preferred
(with STD Code)
*Preferred Mobile No.: Mobile Number
and E-mail ID.
*Preferred Email Id: Mobile Number
will be used for
SMS Banking
Permanent Address: Same as Current Address registration for
eligible
accounts.

City: PIN:

*Landmark:

Telephone:
State: (with STD Code)

Office Address:

City: PIN:

*Landmark:

State: Telephone:
(with STD Code)

Fax: Address proof

Extn.: of mailing
(with STD Code)
address is
mandatory.
Mailing Address: Current Address Office Permanent (You must tick mark one option) Otherwise,
default address
picked would be
Customer Profile Current
Address

*Occupation:

Education: Graduate Post Graduate Professional Others

Gross Annual Income (`): Less than 50K 50K - < 1.5 Lakhs 1.5 Lakhs - < 3 Lakhs 3 Lakhs - < 5 Lakhs

5 Lakhs - < 10 Lakhs 10 Lakhs - < 50 Lakhs 50 Lakhs and above

Residence: Self Owned Family Owned Rented Company Lease

Existing Credit Facility: House Loan Vehicle Loan Consumer Loan Education Loan Business Loan Credit Card

Vehicle: Two Wheeler Four Wheeler Both None

Joint Applicant 1 (* Fields are Mandatory)

Simplified (for low OTP based e-KYC
*Account Type: Normal risk customers) Small Number:
e-KYC
##
(Guardian to fill a Minor Declaration Form separately) If applicable, please attach age proof * Fields are Mandatory
*Name: Mr. Mrs. Ms. Dr. Prof. Capt. Others Existing Customer ID:
(If applicable)
Maximum
32 characters
(First Name) (Middle Name) (Last Name)

Religion: Hindu Muslim Christian Sikh Buddhist Jain Parsi Others

*Mother’s Full Name:

*Father / Spouse Full Name:

*Date of Birth: D D M M Y Y Y Y *Mother’s Maiden Name:

*Residential Status: Resident Individual Non Resident Indian Foreign National Person of Indian Origin

Relationship with Primary Applicant: Marital Status: Single Married

Please fill
FATCA
*Gender: Male Female Third Gender *Nationality: Indian Other (pl. specify) Declaration
Form if you are
U.S.A. or other
*Country of Birth: *Place of Birth: country citizen
/ resident
*Citizenship: *Residence for Tax Purposes: U.S. Person: Yes No

Category: General MBC OBC SC ST Others

Type of card
*Card: Debit Card required Yes No International Debit Card required Yes No Rupay Yes No would be
based upon
Type of card & cheque book issuance would be based the product
ATM Card required Yes No Visa Yes No
upon the product.

*Short Name: Maximum 19 characters.This name would appear on the Debit Card

*Status: Sr. Citizen Pensioner Other General Staff, if yes, Employee No.

*Permanent Account Number (PAN): Form 60 If PAN is not available please fill in Form 60
4
*Aadhaar Number: Your unique identification number

Passport Number: Expiry Date: D D M M Y Y Y Y

Required if
Driving Licence: Expiry Date: D D M M Y Y Y Y Passport or
Driving licence
Voter Identity Card: provide as
Identity /
Address proof
NREGA Job Card:
Others:
(any document notified by Identification Number:
the central government)

*Proof of Address: Passport Driving Licence UID (Aadhaar) Voter Identity Card Simplified Measures Account
Document Type Code

NREGA Job Card Others

*Occupation:

Communication Address:

City: PIN:

*Landmark:

State: Country:

Telephone: *Preferred Mobile No.:

(with STD Code)

*Preferred Email Id:

Permanent Address: Same as Current Address

City: PIN:

*Landmark:

Telephone:
State: (with STD Code)

Joint Applicant 2 (* Fields are Mandatory)

Simplified (for low OTP based e-KYC
*Account Type: Normal risk customers) Small Number:
e-KYC
*Name: Mr. Mrs. Ms. Dr. Prof. Capt. Others Existing Customer ID:
(If applicable)
Maximum
32 characters
(First Name) (Middle Name) (Last Name)

Religion: Hindu Muslim Christian Sikh Buddhist Jain Parsi Others

*Mother’s Full Name:

*Father / Spouse Full Name:

*Date of Birth: D D M M Y Y Y Y *Mother’s Maiden Name:

*Residential Status: Resident Individual Non Resident Indian Foreign National Person of Indian Origin

Relationship with Primary Applicant: Marital Status: Single Married

Please fill
FATCA
*Gender: Male Female Third Gender *Nationality: Indian Other (pl. specify) Declaration
Form if you are
U.S.A. or other
*Country of Birth: *Place of Birth: country citizen
/ resident
*Citizenship: *Residence for Tax Purposes: U.S. Person: Yes No

Category: General MBC OBC SC ST Others

Type of card
*Card: Debit Card required Yes No International Debit Card required Yes No Rupay Yes No would be
based upon
Type of card & cheque book issuance would be based the product
ATM Card required Yes No Visa Yes No
upon the product.

*Short Name: Maximum 19 characters.This name would appear on the Debit Card

*Status: Sr. Citizen Pensioner Other General Staff, if yes, Employee No.

*Permanent Account Number (PAN): Form 60 If PAN is not available please fill in Form 60

*Aadhaar Number: Your unique identification number Required if

Passport or
Driving licence
Passport Number: Expiry Date: D D M M Y Y Y Y provide as
Identity /
Address proof
Driving Licence: Expiry Date: D D M M Y Y Y Y 5
Voter Identity Card:

NREGA Job Card:

Others:
(any document notified by Identification Number:
the central government)

*Proof of Address: Passport Driving Licence UID (Aadhaar) Voter Identity Card Simplified Measures Account
Document Type Code

NREGA Job Card Others

*Occupation:

Communication Address:

City: PIN:

*Landmark:

State: Country:

Telephone: *Preferred Mobile No.:

(with STD Code)

*Preferred Email Id:

Permanent Address: Same as Current Address

City: PIN:

*Landmark:

Telephone:
State: (with STD Code)

Mode of Operation
Self Jointly Either or Survivor Former or Survivor Guardian Anyone or Survivor

Others:
(Please Specify)

Initial Payment Details Please note: All

cheques should
Payment By: Cash (To be deposited by the customer at teller counter only) Cash Deposited on: D D M M Y Y Y Y be CROSSED
and in favour of
Cheque Drawn on: ‘DCB Bank
Cheque No.:
Dated: D D M M Y Y Y Y (Bank) Limited’ A/c
(Your Name)’
Amount Debit to DCB Bank
Amount `:
in words: A/c No.:

Services
SMS Banking & Alert Facility:
Alerts facility enables you to receive alerts on your Email and / or Mobile regarding large debit, large credits, Standing Instruction failure, balance below Account Quarterly Balance and balance
update. New alerts may be added from time to time.
Please Note: Authorised signatory/ies of the Firm / Company / Trust / Association / Society are eligible for free Mobile alert facility subject to compliance of terms and conditions as stipulated by
the Bank from time to time.
I / We don’t wish to receive any Bank related I / We don’t wish to link my/our Aadhaar Number to this account. Please fill a
promotional calls, SMS alerts or emails. (Please Note: Any 1 Aadhaar Number is linked to 1 Account Number to receive subsidy on the account) separate Mobile
Banking
DCB – On The Go (Mobile Banking) Email Account Statement Internet Banking Utility Bills Registration
Form for
Joint Account
Phone Banking Preferred Language Options: English Hindi Marathi Gujarati Tamil Telugu Holder

Passbook Investment: Life Insurance Mutual Fund Wealth Management General Insurance

2-Way Sweep Deposit Details: Facility required: Yes No (please tick appropriate options)

Please Note: Reverse Sweep to Fixed Deposit account shall happen only, if the balance in the account exceeds threshold limit and Sweep shall happen if the balance in the account goes below
the threshold limit. All deposits will be under Re-investment scheme with Auto Renewal Facility, this facility may differ from product to product and from time to time.
Account Statement: Frequency of statement would be as per the product feature.
Form 15G / 15H,
Tax Deduction at Source etc. to be
submitted at the
beginning of
TDS to be deducted if applicable: Yes No TDS Exemption submission date : D D M M Y Y Y Y every financial
year and while
If No, TDS Exemption Reference No. making fresh
deposits during
the year.
Enclose TDS Certificate for exemption.

ONLY simple
Term Deposit Details (* Fields are Mandatory) interest
payable for
deposits of less
Type of Deposit Fixed Deposit (FD) DCB Suraksha FD Tax Saver FD Non-callable FD than 6 months
tenor
Half Yearly Interest Payout
Interest Payout Monthly Interest Payout (MIC) (only applicable for FD)
Quarterly Interest Payout (QIC)
Frequency
Simple Interest (for deposits less than 6 months) On Maturity
6
 Amount of Deposit Please issue Fixed Deposit in the name(s) of

by Cash / Debit to Account No.:

Amount `

(Rupees only)

Date of Birth
Deposit Period Days Months Years (Minimum 7 days maximum 10 years) (DOB) proof
required to
avail benefits
Senior Citizen Yes No Interest Rate . % per annum for Senior
Citizens.
Through
Interest Payment Transfer to DCB Bank A/c. No.:
NEFT
Instructions
Issue Demand Draft Payable at

*Maturity Instructions
(Tick any one) Auto Renew Principal and Interest Auto Renew Principal and Pay Interest Repay Principal and Interest

Mode of Operation Self Either or Survivor Former or Survivor Jointly

Guardian By anyone or Survivor

*Payment Instructions Through

Transfer to DCB Bank A/c. No.:
(upon closure) NEFT

Issue Demand Draft Payable at

Please tick if you wish to receive hard copy of the Deposit Confirmation Advice (DCA) otherwise the DCA will be sent at your registered email ID
with the Bank.

Instructions for payment of interest & maturity proceeds through NEFT

This facility is
1. Mandatory to attach a cancelled cheque of the bank account mentioned below not available
2. Beneficiary Name (As per Beneficiary’s Bank record - should be same as applicant name): for fixed
deposits with
maturity
instruction as
“Auto Renew
Bank Name: Branch Name: Principal &
Pay Interest”
Account Number: Account Type: Savings Current

IFS Code: Overdraft Others (please specify)

Terms and conditions:

I/We abide by the following terms and conditions: 1. It is being understood that the remittance is to be sent at my/our own risk and responsibility and on the distinct understanding that no liability
whatsoever is to be attached to the Bank for any loss or damages arising or resulting from delay in transmission, delivery or non-delivery of the message or for any mistake, exchange or error in
transmission or delivery thereof or in deciphering the message for whatsoever cause or from its misinterpretation when received or the action of the destination Bank or due to RBI (Reserve Bank
of India) RTGS / NEFT system not being available or failure of internal communication system at the recipient bank/branch or incorrect information provided by me/us or any incorrect credit
accorded by the recipient bank/branch due to information provided by me/us or any act or event beyond control or from failure to properly identify the person’s name. 2. I/We understand that the
RTGS / NEFT request is subject to the RBI regulations and guidelines governing the same. 3. I / We agree that the credit will be effected solely on the beneficiary account number information and
beneficiary name particulars will not be used for the same.

DCB Diamond Khushiyali Deposit Details DKD can be

created in the
name of the
Monthly Instalment Primary
`
Amount Applicant only

Deposit Period Days Months Years (Deposit period is minimum 14 days and maximum 10 years)
Date of Birth
Senior Citizen Yes No Interest Rate . % (DOB) proof
required to
avail benefits
for Senior
Monthly Instalments to Debit to Account No. Citizens.
be collected through
on D D of every month

Maturity Instructions Transfer to DCB A/c No.:

Mode of Operation Self Jointly Either or Survivor Former or Survivor Guardian

Others:
(Please Specify)

Declaration where Applicant is Minor

I hereby declare that I am the natural guardian / lawful guardian appointed by the Court order dated D D M M Y Y Y Y (copy enclosed) of

Master / Miss Minor's Name

I shall represent the said minor in operating the Bank Account till he / she attains majority. I agree to indemnify the Bank against any claims for any transactions made
in the account(s).
I undertake and confirm that I shall avail various services of the Bank (wherever applicable) like Phone Banking, Mobile Banking, Internet Banking, Bill Pay only for the
benefit of the minor and I shall abide by all terms and conditions governing the various services and shall intimate the Bank in writing immediately upon the Minor
attaining majority.

*Customer id:

* Incase Father / Mother / Guardian is an existing customer

Name of Father / Mother / Guardian Signature of Father / Mother / Guardian 7
 Nomination Details (Form DA 1) Preferable for
Single & Joint
account
Yes, I want to nominate the following person No, I do not want to nominate anyone holders.
Mandatory for
I / we nominate the following person to whom in the event of my / our / minor’s death the amount of the deposit / in the account may be returned by DCB Suraksha
DCB Bank Limited FD

Nominee Name:

Address:

Relationship with Applicant, if any Age: Years Date of Birth: D D M M Y Y Y Y

Nomination
* As the nominee is a minor on this date, I / we appoint (Name & Address) under Section
45ZA of the
Banking
Regulation
Act, 1949
and Rule 2(1) of
the Banking
Companies
(Nomination)
Rules 1985 in
to receive the amount of the deposit / in the account on behalf of the nominee in the event of my / respect of bank
our death during the minority of the nominee. deposits.

In case you have specified a nominee above, please indicate if you wish to make mention of the
nominee name on the passbook, statement & DCA issued in respect of your account and / or the Thumb
passbook issued to you impression is
Yes No required to be
attested by
I / We do hereby declare that what is stated above is true to the best of my / our knowledge and belief. Signature(s) / Thumb Impression(s) of depositor(s) 2 witnesses.
In case of
Witness(es): signature, no
witness is
required.
Name : Name :

Signature : Signature :
Address : Address :

Place : Date: Place : Date:

*Strike out if nominee is not a minor. ** Where deposit is made / account is held in the name of the minor the nomination should be signed by a person lawfully entitled to act on behalf of the minor.

Group Personal Accident Insurance

Yes, I wish to enroll Yes, I wish to enroll for the auto renewal of
for Group Personal Accident Insurance Group Personal Accident Insurance for additional 3 years 5 years 10 years

Sourcing Staff Name: HRMS Number:

Group Personal Accident (GPA) Plan (Please tick any one of the below 7 options)

Coverage Options Sum Insured ` Premium* Option Chosen (þ)

500000 (AIB only) 444
1000000 868
Standard Variant The maximum
Death + Permanent Total Disability 1500000 1602 Sum Insured
allowed for any
2500000 2670 one customer,
across one or
3000000 3204
more policies,
1000000 1184 should not
Double benefit Variant exceed
Death + Permanent Total Disability + Double benefit for salaried person for accident 1500000 1780 ` 30 Lakhs
(standard
on duty by Rail / Road / Air
2500000 2937 variant only).

*Taxes as applicable

*Nominee:

*Mention Guardian / Appointee Name in case Nominee is a minor:

*Relationship of Nominee with Applicant:

*Nominee Gender: Male Female Third Gender

*PLEASE TICK (ü) AGAINST THE APPLICABLE DESCRIPTION, IF YOU FALL UNDER ANY OF THE BELOW LISTED CATEGORIES. IF YOU FALL UNDER
MORE THAN ONE OF THE LISTED TITLES BELOW, PLEASE TICK AGAINST ALL THE APPLICABLE HEADS.

Head of Stateor Central Government Senior Politician Senior Government / Judicial / Military Officer

Any other Politically Exposed Person (PEP) /

Senior Executive of State or Central-Owned Corporation Important Political Party Official
Related to PEP
List of hazardous occupation which are not covered in GPA: Aircraft pilots and crew, Armed Forces personnel, Artistes engaged
in hazardous performances, Aerial crop sprayer, Bookmaker (for gambling), Demolition contractor, Explosives users, Fisherman
(seagoing), Jockey, Marine salvager, Miner and other occupations underground, Off-shore oil or gas rig worker, Policeman (Full
time), Pop Musicians, Professional sports person, Roofing contractors and all construction, maintenance and repair workers at
heights in excess of 50ft / 15m, Saw miller, Scaffolder, Scrap metal merchant, Security guard (armed), Steeplejack, Stevedore,
Structural steelworker, Tower crane operator, Tree feller, Ship crew, Travel agency business, Air coupon & ticket business.
Signature of the Applicant 8
A worldwide personal accident cover plan that is specially designed to give comprehensive protection to help you / your family against finance
crises due to Accidental Death or Permanent Total Disablement.
Key Features: • Worldwide Cover • No Waiting Period
Sum Insured Options:
Coverage Options Sum Insured ` Premium* Option Chosen (þ)
500000 (AIB only) 444
1000000 868
Standard Variant
Death + Permanent Total Disability 1500000 1602
The maximum
2500000 2670 Sum Insured
allowed for any
3000000 3204 one customer,
across one or
1000000 1184
Double benefit Variant more policies,
Death + Permanent Total Disability + Double benefit for salaried person for accident 1500000 1780 should not
on duty by Rail / Road / Air exceed
2500000 2937 ` 30 Lakhs
(standard
*Taxes as applicable variant only).
Key Benefits:
Death Benefit: In the unfortunate event of a fatal accident, the Sum Insured shall be paid to the nominee of the Insured Person.
In the unfortunate event of an accident resulting in Permanent Total Disability, the Insured Person shall be paid the following % of Sum Insured.
a) 100% sum insured in case of loss of sight of both eyes, or of the actual loss by physical separation of two entire hands or two entire feet, or of one entire hand and one entire foot, of such loss
of sight of one eye and such loss of one entire hand or one entire foot.
b) 100% sum insured in case of loss of use of two hands or two feet or of one hand and one foot, or of such loss of sight of one eye and such loss of use of one hand or one foot.
c) 50% sum insured in case of loss of sight of one eye, or of the actual loss by physical separation of one entire hand or of one entire foot.
d) 50% sum insured in case of total and irrecoverable loss of use of a hand or a foot without physical separation.
e) 100% sum insured in case of permanent and total disability which absolutely disables insured person from engaging in any employment or occupation.
For those opting for Double benefit for Death & Permanent Total Disability cover: Claim will be paid for salaried persons who are involved in an accident on duty while traveling by Rail / Road / Air.
Who can be Insured Person?
This insurance is available to persons who are aged between 18 and 70 years at the commencement date of the Policy and are Account holders of DCB Bank Limited (DCB Bank).
This is an insurance plan underwritten by Royal Sundaram General Insurance Co. Limited (IRDAI Registration No. 102, CIN-U67200TN2000PLC045611) for customers of DCB Bank. Your
participation in this insurance product is purely on a voluntary basis. DCB Bank will be the Group Manager for this insurance product and will only be responsible for distributing the insurance
product to all members of this group. All Claims under the policy will be solely decided upon by Royal Sundaram General Insurance Co. Ltd.
This application shall be processed and the premium amount as per option chosen by you shall be debited if it is found acceptable by Royal Sundaram General Insurance Co. Ltd. The insurance
cover shall start on 1st day of succeeding month of the premium amount debit in your DCB Bank Account (“commencement date”). This insurance cover will be valid for a period of 1 (one) year
from the commencement date, provided you continue to remain a DCB Bank account holder during this period. This insurance cover will cease to exist in case the DCB Bank Account is dormant,
freezed or lien marked for any reason whatsoever. The application will not be accepted till the time such account related disputes are resolved and the said DCB Bank Account is reactivated.
Renewal reminders for this policy will be conveyed through SMS alerts and Email by DCB Bank on the Mobile No. and Email respectively as indicated by the Applicant in this Application.
If for any reason you need to communicate with Royal Sundaram General Insurance Co. Ltd., it is adequate that you mention the Master Policy number, DCB Bank account number and the branch
details. Claim intimation can also be made to Royal Sundaram General Insurance Co. Ltd., by contacting them on 1860 425 0000.
This is only a brief summary of the insurance product. Please refer to Master Policy No. PADCB00001 (available on DCB Bank’s website www.dcbbank.com) issued to DCB Bank by Royal
Sundaram General Insurance Co. Ltd. for complete information on terms, conditions and exclusions.
Royal Sundaram General Insurance Co. Limited, Vishranthi Melaram Towers 2/319, Rajiv Gandhi Salai, Old Mahabalipuram Road, Karapakkam, Chennai - 600097.

ACKNOWLEDGMENT

Name of the Applicant:

DCB Bank Account Number:

DCB Bank Account Opening Form Number: Date: D D M M Y Y Y Y

Instruction received to debit ` ______________ from DCB Bank Account towards Group Personal Accident Insurance Premium.

(Note: Certificate of Insurance will be couriered at your mailing address / emailed on your registered Email ID post issuance of the policy. Insurance cover will start on 1st day of succeeding month of the premium
amount debit from your Account with DCB Bank Limited)

This application is for Group Personal Accident Insurance Cover only. It is not a cover for Life Insurance or Mediclaim.

Applicant’s Signature: ____________________________________ Authorized signatory for DCB Bank Limited: ____________________________________

List of hazardous occupation which are not covered in GPA:

Aircraft pilots and crew, Armed Forces personnel, Artistes engaged in hazardous performances, Aerial crop sprayer, Bookmaker (for gambling), Demolition contractor, Explosives
users, Fisherman (seagoing), Jockey, Marine salvager, Miner and other occupations underground, Off-shore oil or gas rig worker, Policeman (Full time), Pop Musicians, Professional
sports person, Roofing contractors and all construction, maintenance and repair workers at heights in excess of 50ft / 15m, Saw miller, Scaffolder, Scrap metal merchant, Security
guard (armed), Steeplejack, Stevedore, Structural steelworker, Tower crane operator, Tree feller, Ship crew, Travel agency business, Air coupon & ticket business.

Royal Sundaram General Insurance Co. Ltd.

Call 1860 425 0000
Write customer.services@royalsundaram.in
Visit www.royalsundaram.in
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Easy to use with
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ATM Card & your Finger Print
ATM Card & PIN
DCB Bank Limited
 Risk Classification for Primary Applicant
* Kindly fill the following details:
Expected Annual Turnover (`): Upto ` 1 Lakh Upto ` 10 Lakhs Upto ` 50 Lakhs Upto ` 1 Crore

Upto ` 5 Crores Upto ` 10 Crores Upto ` 25 Crores More than ` 25 Crores

Expected number of transactions in a month: Up to 20 21 to 50 More than 50

Basis of Categorisation: Politically Exposed Person Domiciled in Risk Country Trust Sleeping Partner

High Risk Profession Others (Please specify):

Information: Politically Exposed Person due to position / status as:

If Domiciled in Risk Country - Country Name:
Nature of Business / Occupation:

*Details of Customer’s Source of Funds & Estimated Net Worth:

Income from Employment Income from Business Income from Investments Inherited Funds

Others (Please specify):

Risk Classification of Account (L / M / H):

Risk Classification for Joint Applicant 1

* Kindly fill the following details:
Expected Annual Turnover (`): Upto ` 1 Lakh Upto ` 10 Lakhs Upto ` 50 Lakhs Upto ` 1 Crore

Upto ` 5 Crores Upto ` 10 Crores Upto ` 25 Crores More than ` 25 Crores

Expected number of transactions in a month: Up to 20 21 to 50 More than 50

Basis of Categorisation: Politically Exposed Person Domiciled in Risk Country Trust Sleeping Partner

High Risk Profession Others (Please specify):

Information: Politically Exposed Person due to position / status as:

If Domiciled in Risk Country - Country Name:
Nature of Business / Occupation:

*Details of Customer’s Source of Funds & Estimated Net Worth:

Income from Employment Income from Business Income from Investments Inherited Funds

Others (Please specify):

Risk Classification of Account (L / M / H):

Risk Classification for Joint Applicant 2

* Kindly fill the following details:
Expected Annual Turnover (`): Upto ` 1 Lakh Upto ` 10 Lakhs Upto ` 50 Lakhs Upto ` 1 Crore

Upto ` 5 Crores Upto ` 10 Crores Upto ` 25 Crores More than ` 25 Crores

Expected number of transactions in a month: Up to 20 21 to 50 More than 50

Basis of Categorisation: Politically Exposed Person Domiciled in Risk Country Trust Sleeping Partner

High Risk Profession Others (Please specify):

Information: Politically Exposed Person due to position / status as:

If Domiciled in Risk Country - Country Name:
Nature of Business / Occupation:

*Details of Customer’s Source of Funds & Estimated Net Worth:

Income from Employment Income from Business Income from Investments Inherited Funds

Others (Please specify):

Risk Classification of Account (L / M / H):

11
 Declaration Regarding Signing
in Vernacular Language / By Illiterate / Visually Challenged Person

I, Mr./Ms._________________________________________________________________ (the Declarant - either Bank Official or customer of Bank) have read out and

explained the contents of this Account Opening Form of DCB Bank Limited (the Bank) to the Applicant(s) Mr. / Ms. ____________________________________________

in _____________________________ language and he / she / they have confirmed that he / she / they has / have understood the same and have agreed to abide by all

the terms and conditions of the said Account Opening Form. Pursuant to the same the aforesaid Applicant(s) is / are affixing his / her / their signature(s)/thumb

impression(s) as given herein below:

___________ ___________ ___________ ___________

Name and signatures of Applicants Name and signature of the Declarant

Date :_____________ Place :_____________

Letter From Customer – Opening of “NO FRILL” Accounts in “VALUE SAVINGS SCHEME”
under relaxed KYC Norms

The Branch Manager

DCB Bank Limited

____________________ Branch

Sir / Madam,

I / We am / are aware and agree that if the balance in my / our account and / or the aggregate credits in my / our account exceed/s the limits specified by
Reserve Bank of India, I/we agree to be subjected to full KYC norms applicable at that point of time and affirm that I/we shall comply with the same as per
requirements of the Bank failing which, the Bank has the right to suspend the operations or close the account by giving a notice of 15 days.

Yours faithfully,

___________________________________
(Signature of the Customer)

Letter From Customer – Opening of Corporate Payroll Account with Mailing Address as Office Address

The Branch Manager

DCB Bank Limited

____________________ Branch

Sir / Madam,

I am / We are aware of the risks that would arise due to receipt of customer deliverables at the corporate address by any unauthorised person and I / we shall not hold
the Bank responsible and liable for any loss or damage that I / we may suffer, due to the Bank recording and treating the corporate address of my / our company as my
/ our mailing address.

Yours faithfully,

___________________________________
(Signature/s of the Customer/s) DCB Bank Limited 12
 Declaration
I / We have read, understood and hereby agree to the terms and conditions as applicable to my / our account” set forth on DCB Bank Limited (“the Bank”) website at www.dcbbank.com. I / We
understand that access to any changes / updates in terms and conditions applicable to this relationship shall be available on the Bank's website only. I / We do hereby declare that information
furnished in this Form is true and correct to the best of my / our knowledge and belief. I / We hereby authorize issuance of ATM / Debit Card and provision of Phone Banking, Mobile Banking
Services, Internet Banking and Bill Payment Services. I / We am / are aware of charges applicable for various services offered and I / we affirm, confirm and undertake that I / we have read and
understood the “Terms and Conditions” for usage of the Phone Banking, Mobile Banking Services, Internet Banking and Bill Payment Services of DCB Bank as set forth in the Bank's website
www.dcbbank.com and I / We will adhere to all the terms and conditions as applicable from time to time. I / We further authorize the Bank to debit my / our Account(s) towards any applicable
charges for any / various service / services provided as applicable from time to time.
I / We understand and agree that the consent given for updation / registration / requests for free Mobile alert facility shall be valid till such time I / we withdraw the same in writing. Unless
specifically advised, the Bank will continue to send SMS alerts on the number requested by the authorised signatory/ies of the Firm / Company / Trust / Association / Society. The Bank shall not
be responsible and liable for any consequences which may arise owing to change in name/s, address, mobile number of individual, authorized signatory/ies or partners or directors or trustees or
members of the Firm / Company / Trust / Association / Society.
I / We declare, confirm, understand, accept, acknowledge and agree:
(a)That all the particulars and information given in this application form (and all documents referred or provided therewith) are true, correct, complete and up-to-date in all respects and I / We
have not withheld any information. I / We understand certain particulars given by me / us are required by the operational guidelines governing banking companies. I / We agree and undertake to
provide any further information as and when the Bank may require. (b) That I / we have had no insolvency proceedings initiated against me / us nor I / we have ever been adjudicated insolvent.
(c) That I / we have read the application form and brochures and am aware of all the terms and conditions of availing finance or service or products from the Bank. (d) That the Bank reserves the
right to reject any application without providing any reason and reference to me / us. I / We agree and understand that the Bank reserves the right to retain the application forms, and the
documents provided therewith, including photographs, and shall not return the same to me / us. (e) To inform the Bank regarding change in my residence /employment and to provide any further
information as and when the Bank may require from time to time. (f) That if the Account is under corporate salary scheme: I / We have also read and understood “Terms and Conditions” under
which Salary Scheme is offered to my / our organization and employees. I / We agree that my / our employer has full right to reserve any instruction given by them to credit my account for any
amount within a period of three working days and I / we will not dispute or hold the Bank responsible for such debits in my / our account. I / We understand that it is my / our responsibility to
inform (in writing) the Bank immediately on termination of my / our employment with my / our current employer, whereupon I / we will cease to enjoy any or all benefits under Salary account
scheme. I / We understand that the Bank reserves the right to convert my / our account into a regular savings bank account and further ceasing to be categorised as a account under corporate
salary scheme. Accordingly there will be a change in minimum balance requirement and applicable charges per regular savings bank account. (g) That I / we shall not hold the Bank liable and
responsible for furnishing of the processed information / data / products thereof to other Banks / Financial Institutions / Credit Providers / Users registered as above. (h) That I / we have to
complete further application for specific liability products / services from the Bank as prescribed from time to time, and that such further applications shall be regarded as an integral part of this
application (and vice versa), and that unless otherwise disclosed in such further forms as prescribed, the particulars and information set forth herein as well as the documents referred or
provided herewith are true, correct, complete and up-to-date in all respects. (i) That such further applications will require incorporation of the application form number, and / or such details as the
Bank may prescribe, to facilitate data management. (j) That I / we authorize the Bank to issue a Debit cum ATM Card to me / us. (k) That the issue and usage of the Debit cum ATM Card is
governed by the terms and conditions as in force from time to time and I / we agree to be bound by the same. (l) That the terms and conditions of Debit cum ATM Card are liable to be amended by
the Bank from time to time. (m) That I / we unconditionally and irrevocably authorize the Bank, to debit my / our Account annually with an amount equivalent to the fee and charges for use of the
Debit cum ATM Card. (n) I/We, the joint holder(s),agree that in case of death of any one or more of the joint depositor(s), the proceeds may be paid to the survivor(s), on request before due date as
per the mode of operation. The Bank can levy penal charges, if any, as may be permissible by either regulatory guidelines or provisions of BCSBI code or both, applicable as on the date of
request. (o) That continuation of the account with the Bank is at the sole discretion of the Bank and in case the Bank is dissatisfied with the conduct of the account / accountholder, the Bank has
the right to close the account after giving me / us one month's notice or withdraw the concessions in to or any service granted to me / us or charge the Bank's applicable rates/charges for such
services. (p) That the Bank may at its absolute discretion, discontinue any of the services completely or partially without any notice to me / us. (q) That in case of return of Account Opening
Amount (AOA) cheque, for any reason whatsoever, the Bank would close the account without any reference to me / us. (r) That on receipt of written application from any of the Authorised
Signatory(ies) and / or survivor or survivors of us, the Bank at its sole discretion and subject to such terms and conditions, grant a loan / advance / renew / enhance against the security / collateral
issued in joint names. (s) That DCB – On The Go facility will be offered to customers whose account is an individually operated resident account. (t) That DCB mobile Banking will not be available
to Non Resident Accounts. (u) I / We hereby understand that among all other things, minimum balance requirement for variants of savings bank account under various scheme codes would be
applicable and is in line with such updated information as available on the Bank's website www.dcbbank.com from time to time. (v) I / We agree that the non-callable deposit/s cannot be closed
by me/us before expiry of the term of such deposit/s.
I/We understand that the Bank is relying on this information for the purpose of determining the status of the applicant named above in compliance with FATCA (Foreign Account Tax Compliance
Act) / CRS (Common Reporting Standards).
The Bank is not able to offer any tax advice on CRS or FATCA or its impact on the applicant. I/we shall seek advice from professional tax advisor for any tax questions.
I/We agree to submit a new form within 30 days if any information or certification on this form becomes incorrect.
I/We agree that as may be required by domestic regulators/tax authorities the Bank may also be required to report, reportable details to CBDT (Central Board of Direct Taxes) or close or suspend
my / our account.
I/We certify that I/we provide the information on this form and to the best of my/our knowledge and belief the certification is true, correct, and complete including the taxpayer identification
number of the applicant.
Aadhaar Consent:
I/We have voluntarily submitted my/our Aadhaar/UID Number mentioned above and consent to:
§Seed my/our Aadhaar/UID Number issued by UIDAI, Government of India in my/our name with my/our aforesaid account.
§Map it at NPCI (National Payments Corporation of India) to enable me/us to receive Direct Benefit Transfer (DBT) from Government of India in my/our above mentioned account. I/We
understand that if more than one Benefit Transfer is due to me/us, I/we will receive all Benefit Transfers in this account.
§Use my/our Aadhaar details to authenticate me/us from UIDAI.
§Use my/our mobile number mentioned in my/our account for sending SMS alerts to me/us
§Consent for Authentication: I/We, the holder of the above stated Aadhaar number, hereby give my/our consent to the Bank to obtain my/our Aadhaar number, Name and Fingerprint/Iris for
authentication with UIDAI. The Bank has informed me/us that my/our identity information would only be used for demographic authentication / validation / e- KYC purpose and also informed
that my/our biometrics will not be stored / shared and will be submitted to CIDR (Central Identities Data Repository) only for the purpose of authentication.
I/We have been given to understand that my/our information submitted to the Bank herewith shall not be used for any purpose other than mentioned above, or as per requirements oflaw.
DCB Suraksha Fixed Deposit:
DCB Suraksha Fixed Deposit is available only for resident Indian individuals aged between 18 to 54 years. Maximum life insurance cover available is Rs 50 lakh across all DCB Suraksha Fixed
Deposits in the name of the primary applicant. Insurance cover shall cease on account holder attaining the age of 55 years. The insurance cover will be available only to the primary account
holder. In case of premature withdrawal, insurance cover shall cease to exist. In case of partial withdrawal, insurance cover shall reduce to the extent of partial withdrawal. It is required to provide
PAN, nomination and email ID to open DCB Suraksha Fixed Deposit. Waiting period of 45 days shall apply for all non-accidental deaths. Suicide exclusion shall apply for a period of one year from
the coverage start date. Insurance cover on this DCB Suraksha Fixed Deposit is provided by Aditya Birla Sun Life Insurance Company limited ('Insurance Provider'), which is valid for the deposit
period mentioned in this application form, unless communicated otherwise. Insurance cover provided on and during the renewal of the DCB Suraksha Fixed Deposit (if any) is at the sole
discretion of the Bank / Insurance Provider.
Group Personal Accident Insurance Plan: Applicable only to Primary Applicant
(a) That I hereby opt to enroll under Group Personal Accident Insurance Plan (“Plan”). The terms and conditions of the Plan have been duly explained by the Bank and I have completely
understood the same. (b) That I authorize the Bank to debit the above chosen premium amount from my DCB Bank account towards the payment for this Plan. (c) That the insurance cover shall
start on 1st day of the succeeding month of the premium amount debit in my DCB Bank account (“commencement date”). (d) That this insurance cover will be valid for a period of 1 (one) year
from the commencement date, provided I continue to remain a DCB Bank account holder during this period. (e) That in case auto renewal is chosen without specifying tenure, policy will be auto
renewed for a tenure of 1 (one) year by default and applicable premium amount debited from my DCB Bank account. (f) That in the event of an admissible claim due to my death, my nominee shall
be receiving the claim amount. (g) That the Bank shall not have any role in the claim process and the claim shall be processed and settled by Royal Sundaram General Insurance Co. Ltd. (“Royal
Sundaram”), as per the claim process stipulated by Royal Sundaram, from time to time. (h) That the claim shall be processed as per the terms and conditions of the Master Policy No.
PADCB00001 issued to the Bank by Royal Sundaram.
Group Personal Accident Insurance: Applicable only to Primary Applicant
This application is for Group Personal Accident Insurance Cover only. It is not a cover for Life Insurance or Mediclaim.
Section 41 of the Insurance Act, 1938 – Prohibition of rebates -
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 of 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 rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer.
Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be acceptance of a
rebate of premium within the meaning of this sub-section if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance
agent employed by 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.

Signature of Primary Applicant Signature of Joint Applicant 1 Signature of Joint Applicant 2

Please call DCB 24-Hour Customer Care to enquire about your account application status
DCB Bank Limited
 Customer Information & Due Diligence (CIDD) Form - For Primary Applicant
Information Details
Countries where business associates located
(for Businessmen, only)

Source of Funds for Credits in the Account Savings Salary Business Proceeds Sale of Property

Investments Inheritance Professional fee

Other (please specify)

Wire Transfers Expected Into the Account Yes No Value `

From the Account Yes No Value `

Foreign Inward Remittances Expected Yes No Approximate Value `

Customer Information & Due Diligence (CIDD) Form - For Joint Applicant 1
Information Details
Countries where business associates located
(for Businessmen, only)

Source of Funds for Credits in the Account Savings Salary Business Proceeds Sale of Property

Investments Inheritance Professional fee

Other (please specify)

Wire Transfers Expected Into the Account Yes No Value `

From the Account Yes No Value `

Foreign Inward Remittances Expected Yes No Approximate Value `

Customer Information & Due Diligence (CIDD) Form - For Joint Applicant 2
Information Details
Countries where business associates located
(for Businessmen, only)

Source of Funds for Credits in the Account Savings Salary Business Proceeds Sale of Property

Investments Inheritance Professional fee

Other (please specify)

Wire Transfers Expected Into the Account Yes No Value `

From the Account Yes No Value `

Foreign Inward Remittances Expected Yes No Approximate Value `

481-Ver 1.1-March 2014 DCB Bank Limited M026 / Dec 17 / 2.1

Nomination Form Received: Yes No Acknowledgement 0159236

Please provide this number for future reference

1st Applicant’s Name:

Joint Applicant 1:

Joint Applicant 2:

Name of the Nominee:

Name of the Bank Official:

Employee code: Date: D D M M Y Y Y Y Branch:

Signature of Bank Official
 For Bank Use Only
Any of the Signatories / Beneficial Owners of the entity a Political /
Public Figure or related to a Political / Public Figure
Yes No if yes, please give position

Does it seem that the initial Deposit and/or the declared transaction profile is in line _______________________________________________
with the status/occupation declared? Signed in my presence
Name & Signatures of the Officer
Yes No
along with HRMS Number Number
KYC verification carried out by

Employee Name & Code:

Employee Designation:

_______________________________________________
Date: D D M M Y Y Y Y Branch:
Employee signature

Signatures and Photographs

Primary Applicant
Thumb Impression Signature Date: D D M M Y Y Y Y

Please affix
a recent
Please affix
photograph a recent
photograph.

Sign across the photo

Joint Applicant 1
Thumb Impression Signature Date: D D M M Y Y Y Y
Please sign
in “Black Ink”
within
Please affix the box.
a recent “Signature
shall be
photograph considered
for all Cheque
clearances
Sign across the photo and
any future
communication
with the Bank”

Joint Applicant 2
Thumb Impression Signature Date: D D M M Y Y Y Y

Please affix
a recent
photograph

Sign across the photo

Please do not
forget to collect
your
Acknowledgment
slip

Approved by BM / BSOM (Name, signature with HRMS Number) with seal

*Incase of Thumb Impression, “Sign in BM/BSOM presence”
For Office
Confirmation “I confirm having met the Applicant/s in person.” Use Only

I confirm having met Mr. / Ms. __________________________________________________________________________________________________________, in person at

c DCB Bank Limited, ____________________________________ Branch, c Current Residential Address, c Permanent Address, c Office Address (anyone address
as mentioned in the application form) and hereby confirm the identity and address as provided in this account opening form and also confirm having verified the copy
of the documents (as applicable) against originals as produced by the applicant/s.

I also confirm that the form has been signed by the applicant is in my presence. I have also verified the Tel. No. _________________________________ by calling the no.
mentioned in this account opening form.

Name of Bank Official: Mr. Mrs. Ms. Date: D D M M Y Y Y Y

Employee No.:
Signature of Bank Official 15
 Get double the benefits!
Grow your money + Protect your family.

DCB Suraksha Fixed Deposit

Get free life insurance

Earn attractive
cover of the same
returns on your
value as the initial
fixed deposit
fixed deposit amount

Terms and conditions apply. DCB Bank Limited