The Branch Manager Date:

LIC OFINDIA
Branch Office-310
Janpath
New Delhi

RE:- Death Claim in Pol.No.-

fvg. Sh/ Smt-

-Respected Sir / Madam,

I an sorry to inform you that Mr/Mr.

Life Assured under the above policy died on. at

You are requested to lssue datm form at the earllest.

Tlhanking you.
Signeture:
Nominee Name:

Addresst
Mobile not

Documents needed:
Original policy bond
Original Death certificat:
Deceased' s ID
* * * * *

* ***** **

Nominte
Residence proot .
ID proo
Cancelled cheque the
Ifcheque is not haviag the mame of the A/C holder,then photo copy of first page of
pasebook containing details of the A/C holder along with original passbook.
 .3783 2FomNo
LIFE INSURANCE CORPORATION OF INDIA
f i HUZA-L/ OELHI DIVISION.I

t INSUPANCC EDPF ORAT 10N QI 101 7n utera A. i Branch Unit No

ZT17 au CLAIMANT'S STATEMENT

TDe tec" by the ceison tegally entiled to the policy moneyis) All answers to be filed in legibly. Anserg mutl
words. S!rokes c' the pen or dols or dashes cen nol be accepted as repies

in
cceclionv.h claim under Pckcy,No /s lcr Ps S.A

(Insen lull name ol the deceased)

as the claimant under Ihe policy make lhe folowing statement

Particulars regardingthe claimant:

Tn T/Name of the claimant (Shn/Smt)
(1
HTIge-
TT -tA/Address. Telephcne No. and E mail

ela:ionshic ic the deceased life assured

Nalure of title under which the claim for policy money is submilled viz, nominee, Assignee. Executor, Admi
Trustee or Bedeficiary

Fanculars regarding the deceased uie asstureg Sh nl

Plare c Dea!h of the :le assyted_

afu
9ale of Oeait. r a c ' ime ol de3th_

(t) Age of the lile assured at death.

( Ouration of last illhess_

Immediate cause ol dealh_

Last
oçcupalion of the life assure
Las 2ddress the ife as sured_

ui ame ol deceased's lalner (Shr)

Faticsiars reçprd!ng the other policies or. the ile ol !he deceased

SumAsSured Dale o Vhether with Ccuble Accid

Cmmericemenl Extended Cisabi!y Een
 vhen did he deceased first complain
of being not in usual good health ?_

(b) Nature of illness then complained

The names ol the Medical Atlendanls during the last illnes s

Names and address of the doclors, consulled during the last three:years slating againsl each nam.e the scm
which he was consulted and the dale or dales thereof

Dale or dates ol consullalion Name of the Doctor or Hospilal and address Nalure ol Com plaint
....

****** **** **
*******
***** '** *********'********** ******* ****

3 ****
******T*'*****'************'*****'****** ******'***********| **********'**.

*********************************'***"'***" ' * * * * * * * * * * * ' * * * * * * ***

****

do hereby declare ihat the slalemen! made herein a03e

each a d every respact.

Notwithstanding the provisions ol any law, usage cuslom. or conyention for Ihe ime being inforce prohibilirigg any hy:
(os pital from divulginy any knowledye or informalion acquired by him/them in attending upon or examining a person on Ine 9
secrecy. I hereby authorise lhe Physician or Hospital who.has attended Upon or examined or trealed the alorsaid deceased ilea::
3ny ailmcnl or illness to divulge any Rnowledge or intormaion regarding the deceased's state of health which héAhey niay ha.e i
whether before or afler the policy was issued by the Corporaion, te the Corporalon. its ofices, and legal advisers er in any tcun
I (TET)..
Declared al_ this _day o 20 before me

SignaturefThumb imçiession ci :he i e

Counler Signed b;
T4/Name
R/0esignation TZ/Designaion
iAddess To1/Address
Hi TAMTU(Signature' of wiliess
BiOesignation
TYAddress_

If he. Declatanl signs in vernacular or affixes humb'impression the wilness should also sign th following Declaralic

Cenified that the contens of this form were explained to the declarant in vernacular and he/she has a fixed his/her sig
Ihumb impression hereto ater fully underslanding the same.
HTEN EIAUSignalure ef wilness.
R/Designation

, 5 . TRY T y 6,3TZT 7. TTsfsa ofiraTd, 8. FNaf7 faurea 4ATaTd 9. jm zrTVTFT faTiTa 37S7

i s slalement must be contersigned by (1) an Advocate (2) an gent of the Coporation (Who is a member of ar ge
a Cee Oivisionaltdanagers Club (or above). (3) a Bank Manager () aBlock Development Öfficer. (5) Commissione c'
B c o ( ! a Gazeted Officer. (8) a Head Masler of High School, (9) a Head Post Masteror Departmerial sut Fos: l.tasiertu
nch Post tMaster) (10) a Magistrate, (11) an Officer or Supeinlendent or a Development Officer (who has ser.ec allie &!
eEdm*l Giice, cf the Corporaion or (12) Presldent of a village P anchyal or Local Board
 (Rev 88)
Form No. 3801
V.P 400 Pads / 08-2016

LIFE INSURANCE CORPORATION OF INDIA

DELHI DIVISiON-1

LIC
INSURANCE CORPORATION OF INDIA
(Established by the Life
Insurance Corporation Act.,

Branch Unit No..

1956)
*********'******'*****

LIFE

.....Dated.. * * * ******** ** **

Discharge of Death
Claim Under Policy No. . . ****************

************'** *********'********** ****'*************

/Master
the life of Mr /Ms
*****************

on
****************
the
'*****'****
.

*********** ** virtue of the

/We
Legal Representative(s) of the above
named Life Assured, by
Nominees(s) Assignee(s) granted to me/us by
Nomination/ Assignment Legal
evidence of title dated. *********

do hereby acknowledge receipt from the

.. ** **** ****************************

the . *******
'*****''*
'

Life Insurance Corporation of India

the sum of Rupees (In words) ************
**************°****'''

**********************:** ***********

on the
** *** ***************************************

demands under the above menttoned policy

********

In full and final settlement and discharge

of all my/our claims and which policy is
. a n d
died on..... ********
*********

mentioned person who *****'****'******* **** .

life of the above
cancelled:
hereby delivered upto the said Corporation tobe
DETAILS OFRECOVERIES
DETAILS OF PAYMENTS Unpaid instalments of premim
Sum Assured/Paid up vaue Rs. ****************** ****

Bonus Alloted/Loyality Additions Rs.

due in the policy year of death Rs.. ***********************'
Late Fee thereon Rs. .* ************
Interim Bonus Rs. ****************

ina' Additional Bonus Rs. *************

A.N.F./Debt. Rs *********************.

Difference of premium X-Charge R ****************"**

on account of over Loan Rs .

RS. Interest on Loan Rs. ...

statement of age . *****"*****

Refund of extra premiums for Amount recoverable on

Sex DAB & EPDB and Occupation account of under
Gross claim amount RS. ********************* statement of age RS. ..- ....... ..***
* ************ *********

TOTAL DEDUCTIONSS
* * * * * * **************

*****"*******

. . (Rupees (in words)... **** *** ************.************* **** ....

Net Claim Amount. Rs. . *** ***** *****

day of . . ......20.
Dated at .. I S .....| ******'*** '**0 *****"***

Revenue
Stamp of

Signed by Mr /Ms... ***********************"***************'*****'**" Appropriate

value
In the presence of
Full Signature of Witness... Full Signature(s)/Thumb impression of the
Full Name **'*******'****************'***** *****'
Claimant(s)
Designation ****
****'*************'*** ******'
Wife of Shri... ******* **.

Address '****'*****'***** ''******** * ****

Son/Daughter of Shri. * * * '

. . .. . * *** ***************''****"**

of an Agents Club at
Nole. This statement must be countersigned by (11 an Advocate (2) an Agent of the Corporation (who is a manber
level of Divisional Managers Club or above) () a Bank Manager (4) a Block Development Officer (5) a
Commissioner oi Oaths (b)
the
a Doctor (7) a Gazetted Officer (8) a Head-Master of a High School (9) a Head Post Master or Departmental Sub-Post Master but not a

Branch Post Master (10) a Magistrate (11) An Officer or Development Officer of at least 3 years standing (12).Acontimed Development
from Agenis wno
Oficer recruited from the DM or BM Club Members before joining or Development Officer recruited
Agents who were
were ZM or Chaiman's Club members before joining (13) President of a Village Panchayat or Local Body.
SIGN THE FOLLOWING
IF THE DECLARANT SIGNS IN VERNACULAR OR AFFIXES THUMB IMPRESSION, THE WITNESS SHOULD ALSO
WERE EXPLAINED TO THE DECLARANT IN VERNACULAR AND
DECLARATION CERTIFYING THAT THE CONTENTS OF THIS FORM
HESHE HAS AFFIXED HIS/HER SIGNATURETHUME IMPRESSION HERETO AFTER FULLY UNDERSTANDING THE SAME

Signature . Full Name..

PG-10000/10/11.
ZT1 -I/Form No 3784

LIGuFEINSURANCE CORPORATION OF INDIA

fRcet yre/Delhi Division - Il

T I a t Ho/Branch Unit No..

MEDICALATTENDANTSCERTIFICATE (Claim Form'B')

(To be completed by the Medical Attendant of the deceased in the last illness)

connection with Clam under Policy No *********

****** ** *** ***

** *'**'******************************** *
***** ***** *** *********************************
( T r TI RI A/nsert full name of the deceased)

T/Nme. ..... ..... . ****.*********.*.****** * * **

(a) What was the full name, address and occupation uET1/Address . *** **" ****************'**
ofdeceased ?
24HTaOccupation. *** * *************************************

*****"******
**********************************

Year
(al His apparent age at the time of death as could be (a
judged?

(b) Was he related to you and if so, how ? (b)

()
fafrE 3H f y ?
c)Description of any marks or Physical peculiarnlies (c)
noticed by you for purpose of identification.

(34) aiT/HTa
(a) Time of death (a) ...
.. . AMPM
(a)
(b) Date of death D) .... .****" *********************'***

(a)
d) Place of death {Give exact address) (c) *** * *** ***** ********* *:* ***** ************* **********

(a)i)Primary cause
fdaro i-F7 n rm T i i7d AI R { ) Secondary cause
(a) What was the exact cause of death ?
Besides defining the o:sease or other cause of dealh
in such terms as y ou censide:
appropriate, kindiy
add the dist1nctive technical name.

(b) Was it ascertained bv evamtation after

death or (a)
refferred form syniptoms and aPpearace during9
life?
(b)
 2

(c) How long had he been suffering from this

disease before his death ? c) ******'***''*''******* **** *********** ******'*****'** **********'*****

(d)Whatwere the symptoms of the illness ?

(d) ****************"******"*****************************************.** ..

(e) When were they first observed by the deceased ?

(e).****************"*;**************** * *****"**** ... .

()
()
() What was the date on which you were first
'T********************** ********* ************************************
consulled during the illness ?

3yTRf ?
(g) Did you attend him during the whole of its
(9)
cOurse? If not, state during what *********** * * * * ' * * * * ' *

period
5.

(a) Were his habits sober and temperate ?

*******'**'*************'***
********

********** ****

(a)

(b) Have you any reason to

suppose or to suspect that
disease was in his case casued or
(b **
******************************** ********* * **************** ***
aggravate by
intemperate habits ?

6.
(1)

(2)

(1) What other disease or illness (i) preceded (ii) or

(1). *** * * ******** ****
co-exsited with that which ***************************"
immediately caused
his death ?
(2) Give history of such disease or illness stating ? (2 **

()
(a) Date when first observed 1?
(a). ***** ********** '**''**** ***************** *** **************** **** ***

(a) fÀ JUuR fra

(b) By whom lieate:d
(b) ..

(c) By whom history reported Ie you

 3

his last ilness by (a) . . *********

(a Was the deceased treated during
or in any hospital
any other medical practitioners
state
were consulted ? H, so please
before you
their names and addressed.

****** ****** ***'**

t Did any other Medical Practitioners

attend on him (b
in consultion wilh yourself ? If so, please
state their names and addresses.

f r à? ()
(37) 7 T TT ufarfRas Attendant ? (a). ***************************** *****
Medical *********************

(a) Were you deceased's usual

***********'*** ***'*********************** ***************************

(b) f so, for how long?

)
T

If not. please slate name and address of his (C) . ***************"'

USual medical attendant ?

When and for what ailment did you treat the deceased
?
during the three year preceeding his iast illness

Was any inquesl or normal enquiry he d regarding thee

death or Post Mortem Examination of tUhe body made ? f

so. whom and whatwas the result or finding?

Have you any other information or renmarks to make in

connection with his claim concerning seceased's
ilienis. habits, mode of living etc.
 ****

*****'******************* *********** **** ******************* **

* * * '

****** *** * *****es**************

Medical Atlendant of the deceased.. ..
statements are true
HEREBY sOLÉMNLY DECLARE that foregoing
************* ****************** ***** . DO
and correct to the best of my knowledge and belief and that the deceased did not die by his own act

***.*-****. ************* *
200
7eTA **************--* 0 a y o l ------------ 200

Daled at.--- -----------~--------- ----*--*** ihis ~--

authorised Medical
Code No. - - - - ----(State here Code Number if you are an

Eaminer of the Corporation)

Signalure of Medical Atlendant

n e s s to signature and idetity of
Medical Atlendant

R/Signature *****************************

EvIR/Signature * ** * *************************************|

/Full Name..
**********************°***********
qrad Qualification.. ************************************

7 1/Occupation. A TAER 7I 1/Postal Address *************' *'**:

TER 1 Y1/Postal Address..

********************************* ******'*'*********'*******************

. . .. . . ..-..
**************:** ****** * .

f ERI ufdermerka ET TTY: (1) a b a (1) AA T aoai. ( RsF rarers-zTa 312r TN JA

r zMa-T e ) (3) xIRa (4) Trs fanra sfecmr?. (5) zwa 3ryan, (6) FE7 7)
T ar.(8) EiE geTEzT27 (9) 3UA ermfrra gu-3Tmua(T7 TTA T) (10)

T T E TI ) *2ra (12) m ra 31era zuta ufue m T

Note the Medical Attendant is a Civil Assistant Surgeon or one of the the Corporation's aulhorised Medical Examinar, his
Signature to this Certificate may be witnessed by any person of known character and rasponsibility other than relative of
the deceased. In other cases, this stalement must be counterisgned by (1) an Advocate. (2) an Agent of the Corporation
vho is a member of an Agent's club at the level of Divisional Manager's Club or above (3) A Bank Manager (4) ABlod
Development Officer, (5) A Commissioner of Oaths, (6) A Doctor, (7)AGazetted Office: (8) A Head Master of tigh School
9A Head Post Master or Department Sub Post Master (but not a Branch Post Master, (10) A Magistrate.
A n Oficer or Development Officer (who has served at last 5 years as Development Oficer of the Corporation) ar
12) President of a village Panchayal or Local Board.
 yyA o 3816 B Form No. 3816 B
VP-400 Padsx50/08-22016
CORPORATION OF INDIA
LIFE INSURANCE
Division-t
qu37-1/ Delhi
fa Office...
ITET Tqtea A/Branch

TREATMENT
CERTIFICATE OF HOSPITAL

....a4 M/TAI.. ****************************

q f T H H o .**********************************************
..

* ***********************************'***************

No. ****

In connection with claim under Policy

.

*******************'****************************************'*************

on the lfe of. .*** ***** ***

********************************"******"********'******

(insert full name of deceased)

of the patient as per Hospital Records?

What was the full Name, age, address and occupation
* ******* ****************'******************************************

**************************************************'*****************

HVName . .... * :
******************************************************* ****
******************************'** **** '*********** ************
31Age *'**********'********************************************
****************************************"********************'***************

TVAddress ***
* ***************************"
***********************************'****** ****** *******'************** .-.
** *

***** *************** ***********************************'**************

******** *************************
* **
4HVOcupation. *************************************

T E dentification Marks... * * * * * * * * * * * * ***

***********
*°
*****
**********************.
**********************************************

*********************
**************************** ********
*****
* * * * ** * * *

2.

was the date of his admission into the hospital

?
What
Please state his indoor admission No.

3.

the patient before he was admitted into the

Under whose treatment was
from any doctor at
Hospital? if the patient had brought a letter or a note
the time of admission kindly furnish us with a certified copy thereof.

At the time of admission what was

(3H) a)
(a) the nature of his complaint
(a) b)
b) the duration of the complaint as reported by him ?
(3) a)

al What was the exact history reported by the patie t

at the time cf adm1ssion? (Full history including tr2 dates
duration of the aiments, the symptoms narrated etc.
to be given)

lf/herself ?
a) Was the history repcrted by the patient humis

(ü) lf not, by whom 7 (Name and relationship of :he person who reported i)
Was the patient present at that time and was he/she conscious?
(A) c)
c) Who recorded the history in the case sheet?
( d)

d) Whether the Doctor who recorded the h:s: ry is sti!! in your service
If not, piease state hus,her full address
 What was the diagnosis arrived at in the Hospital ?

Was there any other disease or illness preceded or co-existed with the
ailment at the time of his/her admission into the hospital? If so what was it?
Please give history of such disease or illness stating.
(7) a)

(a) Date when such was first observed by patient

(a) b)
(b) By whom treated
(T) c)

c) By whom the history was reported ? (If not by the patient

himself/herself, please indicate if it was in his/her presence
and to his/her knowledge)

() d)
d) Who recorded this history ? (If the docto is not with the
hospital at present, please give hisher present address)

9.
What was the date of his/her discharge from hospital?

10.
What was his/her condition when he/she was discharged?

11.

Was he/she treated in the Hospital on any previous occasion

either as an in patient or an out patient,

Ifso, please state

(3a)
(a) Date of Ist admission or first time treatment as an out patient.
( b)
(b) Date of discharge & condition on Discharge.
(H c)
(c) Nature o' ailment.
( d)
(d) History re orted at the time of admission

Certified that the above information is correct as per records of the Hospital.

fkTT/Date KTUSignature Hhd eCode No

Name of Doctor who signed this formon behalf of hospital

Qualification and Designation.

Name of Hosp1tal Postal Address * **********'**********************

* ***********

*
** ***********

2'e mere the coue No ifyou are an authorsed Medcal Examner cf Lfe l2surance Cornnatvsinta
SOP20Paosr$0 0?/05 Form o.
Claim Fo

9 f e Jnsurance Corporation of Jadia

a / D E L H I DIVISION-I

Lendicateof lgenii ang Burial or Çremation

Sranch Uni No

To be completed and signed by a person of kn own character and r spe ctability acquainter
bu not related to the deceas ed-nor lo the ctaitent, and who saw the dead body or who was pres
the burial or ceremation ol the body of thedoceased)
In connection wilhclaim under Policy No.. ************** *** ***********' ***r **°°. * *l.***** *** **.
Shri/Sml./Km.... . ***** ********* .. ereby. make the lollowing siate
(tnsen fult Name -othej deceased)

1. Name ol the dece ased in Iull

Name ol deceased's laihe: in full.

3 (a) How long was the deceased known to you?

WastreTelaled to you ? I sohow?

. (a). Dat6 and ime of death.

(b) Cause ol death.

(c) Place of death.

(d) Duration of iness.

(a Describe any distinctive mark ol physical peculla:ny

of deceased

IbWes he,tall, short or me dium In heigh'7

i 2 s he stoui, ihin or medum in build?

id pprCYimate aga a:death?

Cecease d's occupation imme dialely prior to de :th wih

address o: the employer, i any.
 (2)
7. Leceased's previous ocçupation with address ol the

Employer, i,any
alive?
8. (a) When did you last soe him
Oid you see tha body atter daath?

Was the.bocy burled or cremated?

(c)
(d) Time and daBe of burial or cremalion.
(e) Name ad addrasses of place ol burial or ctemation?
of disposal of the bocy?
Were ybu present al the ine

the deceased's lide was insured

9. Are you aware
that
wth the OCorporaltion2
hereby de clare th
burried or cre mated was thal of the person named and do
.I carnity"thal the body whch'was
are lrue and correct lo the best of my knowledge and beliel.
loregoing slatements
Signature of Declarant...

-Nama al Declarant..
Occupation.:***°***°*** ******* ************* **|
.
Address....
**** ******:**********.***°*********** *

*******************"***°*'°*******************'** *****

Completed and doclared belore me this.. ******"****** ** ** ********* ..day Z00......

.************************"

Signalure cl Declarant.
(Please see nole below)
Full Name..

Occupation..********* ********** ***"****

AddresS.....
**************"* .*************************
***.*'* *******'*" ******.

Note This lorm must be compleled belore (1) an advocate (2)

.
an
hgent of Corpn, (who is a me
of the club al. the leveB, of Divisional Manager's club and aboye). (3)a Bank Manager, (
Commission gr Oaths, (6) a Doctor, (7) Gazeted Of
Block Develop met Officer, (S) a
School, (9) a Head Post Master or Oepartmantal Sub-Post M
(8) a Head. Master of High
Magistrate, 1) an officer or
Supe:indent to Oevelop
(but not a Branch Post Master). (10)
a

least or 5 years as Development Ofticar ot the Corporation

Otfic er (who has served at
(12) President ol a Village Panchayat or Local 8oard.
**** **

Cerlified that the contents of thls Cerndicale were explaine o lhe declarant in a Fegional Languaga 2d the gaps illed in

dictation.

Signature of Witness... ***********.

Full Name..
Occupation.. '******************************************
Address.**** "' * **'.* ************* ********

**** ***** * * * * * * * * * * * * * * *******************'*****

VP-400 Pads X50/08-2016 w7 o 3787
Form No. 3787 (Revised)

* LIFE INSURANGE CORPORATION OF INDIA Calim Form 'E' (Revised)

f t yusc - I/Delhi Division-

Branch Office.
CERTIFICATE BY EMPLOYER

In connection with Claim under Policy No.. **************** *******************

on the life of... *******.*.**..*.*r**

* * * * * * * * * * * * * * * * **'***** I hereby make the following statement

(Interest full name of the deceased)

* *******************.** *****.*************** ********************************** **** ****** .

(a) Name in full

2
********** **************************************************°********************°°********** **************

(b) Address of deceased

3 () f4s i ThR ...

************** ********************************
*****

(c) Nature of Employment

********************** **** *** ** ****************************.

************

(d) Date of joining Service

******************:********************************************************** .*.-**.*.**..*.
(a) Date on which the deceased last attended duties

2 (a) (i) YA7 À 3Tm TE fTATa faa fafa *****° *********************"************************ **** ****************

(b) On which date did deceased fust complained of

liness which caused his immediate absence
before death? and

***********'******************************************* *****************************

(i) Symptoms complained of

( ) T i fafa * ***************

(C Date of deat

******** ********************************************

(d) Who nformed you of the death of the deceasec ?

. . . .*********************** ***************************
(e) Approx1mate age of dece ased at death

3 A15.
*********************"
T F 3afiu fterfa fafaams
**************

************ **** *****

* ************ ****

*** ** ********************* ***

 3 Record of Date of Nature of leave Ground on In the case of
absence from leave availed Casual which leave sick leave
duty during from or Privilege
the period sought for whether
0...... ************ or Sick
Medical
from.. ************"

Certificate
(O..... *****
Produced
* ******************** ******************************* ******************************.**** .* *
*****************************************
******************************** ** ........
** ********
***************************************************** *** *********'*"'**" ,.. .. ....

****'*****"* **
*** *********************** * *

*************************** ***°*** **
*******************""''******"********************************************'**** *****'****'*****'*
******'***********'* **** ****
**********************'** *************************s****** * * *
************'****"****'*************

(N.B.) Please state nature of leave availed of Casual, Privilege, Sick etc. if on
medical certificate was grounds of health, please state whether
produced and if so, send copies of leave applications and certificates.
4.

**************** ******T************************************Tc5

4. Is there any Medical Benifit Scheme for the

employees
in your Office? If so, kindly give the
particulars of the
illness and treatment for which disbursements were
made under the Scheme to the deceased
during the
Ferid from.. ***'*****'** ********************************* * * *** ***************************** *************
*********************.
*********'***

*** ** ************************°* *********** *******

****'************
***'* **** * '****'*

This pericd should commence from three years prior to the date of commencement of risk date of
revival and end with the date of death. Office should indicate the
period with refereDce to the particular
policy before issuing the form.

Signature of Witness Signature of Employer

Designation_
Designation
Address
Address
Date_

******************'*** ************

if the Certificate is signed in

NOTE not be a relative of the deceased nor a claimant under the policy
Ihewitnessbymust
Vemacular the Declarant the witness is required to state below that the cortents of ihe Certificate were explained

to the Declarant in Vernacular and the gaps filled in at his dictation

 CORPORATION OF INDIA
LIFE INSURANCE
TRANSFER-MANDATE FORM
FUNDS
NATIONAL ELECTRONIC
To CORPQRATKON OFINDIA
LIFEINSURANCE
Branch-

payment through NEFT

Sub:Recelpt of pollcY polic; payment througn
NEFT
Bank account for receiving
the details of my
Iam giving below
1) Policy No/s

claimant
Name of policy holder/
(2) Bank Name
(3) Bank Branch Address
Savings/CurrenUCash
Credit/NRI
(4) Account Type
5) Account No.
should be written
from let to right)
(Bank accountnumber

(6) IFS.OCode:

(7) Mobile number.

(8) E-Mailld to your LIC policies":*

related
to seceive SMS/E-mail, on matters
(9) Are you witEng Yesn 0

document to this
effect. (Please v appropriate item)
Ihave enclosed the following

A. Cancelled cheque lea n a m e of bank

holder then Photo copy
of the
the accounts number,
IFS code
8. if cheque is not having delails ol Bank
book containing
page of Bank pass

Date ****

hofder
Signature of the policy Branch
***

subrnit the same to Our

form again and
please fill this mandate
in Bank details, transfers money
to
(ln case of change send you a message
when LiC
whicn
T r a n s e c t i o n Reference jnumber
will be able to
office) n o 9 1s
'Yes', then v e UTR (Unique
°If your a n s w e r to Q message
wi!l contain the
This
your Account
through NEFT. the payment.
enquiry regarding
can be used to make any