CLAIM FORN NO.3825

Form No.
3825
LIFE INSURANCE CORPORATION OF INDIA

MACHILIPATNAM DIVISION
(Established by the Life Insurance Corporation Act, 1956)
………………………………………….………….… Zone ……………...……………………..………..…………………………………… Divisional/Unit Office
…………………………….……………………………….………………………………………………… Branch
Discharge of Matured Policy No. ……………………………………………………………………….………………….
……………………………………………………
Dated ……………………………………………… On the Life of Shri/Smt. ………………………………..
………………………………………………………………
I/We ……………………..
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………..……………………………………………………………………………………………………….. the
Life Assured/Assignee(s) by virtue of the assignment date ……………………………………………………………………………….…
Do Hereby acknowledge receipt from the Life Insurance Corporation of India of the sum of Rupees (in
words) ……………………………………………………………………………………………………………………………………………………………………….……...
including the amount of Bonus, in full and final satisfaction and discharge of all my/our claims and
demands under the above mentioned Policy which matured on …………..………………………………......
………………………………………………………………… and which Policy is hereby delivered up to the said Corporation to be
cancelled.
Sum Assured Paid-up Value Rs. ………………………………………………
Bonus allotted Rs. ………………………………………………
Interim bonus Rs. ………………………………………………
Difference of premiums on account of over
Statement of age Rs. ………………………………………………
Refund of extra premiums for Sex. DAB & EPDB
and Occupation Rs. ………………………………………………
Gross claim amount Rs. ………………………………………………
Less: Unpaid installments of premiums due .. .. Rs. ………………………………………………
Late fee thereon .. .. .. Rs. ………………………………………………
A.N.F. Debt .. .. .. Rs. ………………………………………………
Loan .. .. .. Rs. ………………………………………………
Interest on .. .. .. Rs. ………………………………………………
Amount recoverable on account of
Under statement of age .. .. .. Rs. ………………………………………………
Net claim amount .. .. .. Rs. ………………………………………………
Dated at …………………..……………..………………… this day of ………..………………………….………………….…20…………….
…………………………….…
Signed by Shri/Smt.
In the presence of * …………………………………………………………………… Revenue

Signature of witness ………………………………………………………………… Stamp Of
Full Name ………………………………………………………………………….………… twenty
Designation ………………………………………………………………………..……… Paisa
Address …………………………………………………………………………………………
…………………………………………………………………………………………………………
(Signature(s) of the
Claimants(s) in full)
NOTE : (1) Payment will be made by a crossed and order cheque. If payment is desired by M.O. or a
demand draft, it can be made at the claimant’s cost and at his/her risk and responsibility, on
his/her signing the following note of request.
I/We hereby request the Corporation to pay the aforesaid amount by
……………………………………………….…………… M.O./Demand Draft on the
…………………………………………………………………………………………………….……………………… Bank,
……………………………………………………………….…………………………………………………………………………..…… At my/our risk
and responsibility. I/We further agree to M.O. Commission/Bank charges being deducted
from the claim amount.
(Signatures of the Claimants)
(2) this discharge Form must be signed by the Life Assured and witnessed by a credible person
who is conversant with the language of this form and knows the life assured.
(3) If more than one person have signed the Discharge Form, the name of all the persons should
be stated.
(4) “In case the claimant affixes thumb impression or if this form is signed by more than one
person and payment is desired to be made to only one of them as per the following Note of
Authority completed and by all of them, the thumb impression or the signatures on the letter
of authority must be attested by an Agent of the Corpn., (who is a member of the club at the
level of Divisional Manager’s club and above), a Block Development Officer, a Gazette
Officer, a Magistrate, or an Officer or Development Officer (with at least 3 years’ service as
Development Officer) of L.I.C or a Bank Manager of a Branch of State Bank of India or of one
of the nationalized banks (Provided the attesting Bank Manager signs after affixing an
official rubber stamp giving his name and designation as also the name and address of the
Bank where he is working) or the Principal/Head Master of a local High School or Higher
Secondary School run by the Government. Where thumb marks are affixed, the attesting
official must make the following declaration under his signature :
“Shri/Smt. …………………………………………………………………………………………….……….………………………………………………… son/daughter
of Shri ………………………………………………………………………………………………………………..………………………………………… and wife/widow
of Shri ………………………………………………………………………………………………..…………… has affixed his/her thumb marks In my
presence after understanding the contents thereof.”
(5) Since our records do not show that the final premium due on ………….…… under the policy Has
been paid, we have proceeded on the assumption that it remains unpaid and have
Calculated the claim amount on that basis. If, however, the said premium has been already
paid the amount thereof will be refunded along with the claim amount. To enable us to trace
the payment of premium if already made, please inform us the name of the office or bank
where it was paid and the date and number of the deposit receipt issued therefore. If the
policy is under salary savings scheme and premiums shown as unpaid in this discharge are
already deducted, please obtain and forward a certificate from the Employers giving
particulars of the payment.
_________________________________________________________________________________________________________
_____
Place ………………………………………..… Date …………………….
…… We hereby authorize and request the L.I.C of India to pay the within mentioned amount of Rs.
………………………………………………………………………………..……… to Shri/Smt.
……………………………………………………………………………………… Signed by the parties within mentioned in the presence
of:-
(1) …………………………………………………………………………
(2) …………………………………………………………………………
(3) …………………………………………………………………………
(Signature in full)
Witness: ……………………………………………………………………………
Signature: ………………………………………………………………….....…
Full Name: …………………………………………………………………………
Designation: …………………………………………………………………..…
Address: ……………………………………………………………………………
I certify that the contents of this Note of Authority were explained by me to Shri/Smt.
……………………………………………………………………………… and he/she/they have agreed to payment being made to
Shri/Smt. ………………………………….…..…………………………………………the authorized party.
(Signature of the Witness)

CLAIM FORN NO.3825

Uploaded by

Copyright:

Available Formats

CLAIM FORN NO.3825

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CLAIM FORN NO.3825

Uploaded by

Copyright:

Available Formats

Form No.

LIFE INSURANCE CORPORATION OF INDIA

In the presence of * …………………………………………………………………… Revenue

You might also like

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.