FBS Application Form

Family Benefit Scheme, IMA Telangana State. Any Life Member of IMA up to 60 years of age residing in Telangana is eligible.

Option 1

Manual submission

Print the form, fill it in block letters, attach your photo and certified copies, and send it to the FBS office with your Demand Draft or Cheque.

Download Blank Form

Option 2

Fill online

Fill the form below. Use Export PDF any time to download it filled in. Log in to save it, submit it and edit it later.

Fill Online

Applicant details

Surname

First name

Name of Father / Husband

Sex

Date of birth

Qualification

IMA membership

Name of Local Branch of I.M.A

Name of State Branch of I.M.A

I.M.A H.Q L.M. No

Contact

Correspondence address

State

Pin code

Mobile number You will need this to check your application status.

Telephone (Resi)

Telephone (Clinic)

STD code

Nomination

Up to four nominees. Each nominee's Aadhaar number, signature and photo are added on the printed form.

Nominees

Motivator

Motivator name

Motivator mobile

Payment

Payment details

Demand Draft or Cheque payable at Hyderabad, in favour of "FAMILY BENEFIT SCHEME IMA TS".
Online / NEFT / RTGS / GPay / PhonePe / Paytm: PNB A/C No 1969000100082235, IFSC PUNB0196900, Branch Koti.

How will you pay?

Amount (Rs.)

Documents

JPG, PNG or PDF, up to 5 MB each.

Passport size photograph

Certified copy of birth certificate

Life Membership Certificate of I.M.A.

Medical Council Registration Certificate

Declaration I, the undersigned, hereby apply for the membership of Family Benefit Scheme I.M.A TS. I do hereby declare that the above information is true and I have withheld no information whatsoever regarding the application and I agree to pay the amount demanded as per the death of member of this scheme. I further agree to abide by the conditions laid down in the constitution.

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