Saturday, 21 April 2012 18:10
LIC Survival Benefit Claims Form
Text of the PDF document(for quick reference)
DISCHARGE OF –
(1) * CASH OPTION UNDER C.D.A. POLICY
(2) * MATURITY PROCEEDS UNDER TRIPLE BENEFIT POLICY.
(3) *ANTICIPATED INSTALMENT UNDER ANTICIPATED ENDOWMENT POLICY, MONEY
BACK POLICY, CASH & COVER POLICY & ANTICIPATED WHOLELIFE POLICY.
(4) Return of 50% Premiums under Children’s Anticipated Policy.
Policy No. ___________________________ on the life of ____________________________
the Proposer/Life Assured do hereby acknowledge receipt from the Life Insurance
Corporation of India the sum of Rupees ________________________________ in full
satisfaction of all my claims and demands in respect of the following payment under the
above Policy in terms of the Policy contract, for which the Policy is hereby delivered for
(1) Cash Option which fell due for payment on ___________________ under the
above Children’s Deferred Assurance Policy.
(2) Sum Assured which fell due for payment on the date of maturity, viz _______
under the above Guaranteed Triple Benefit Policy.
(3) Anticipated instalment which fell due for payment on __________________
under the above Anticipated Endowment Assurance Policy/Money back
Policy/Cash & Cover policy/Anticipated whole life Policy.
Return of 50% of Premiums excluding extra Premiums, paid till the Deferred Date,
which fell due for payment on ___________________________ under the above
Children’s Anticipated Policy.
Amount Payable _______________________ Rs. ______________________
Less Unpaid Premium Rs.
Interest on Premium Rs.
Policy Loan Rs.
Interest thereon Rs.
Other deductions Rs.
Net amount payable Rs. __________________________________
*Strike Out the three which are not applicable
I/We hereby declare that I/We have not served on any Office of the Life Insurance Corporation of
India any notice of assignment or reassignment in respect of the above POLICY/IES except those, if
any, already registered by the Life Insurance Corporation of India or the Insurer who issued the above
POLICY/IES nor shall I/We serve on any office of the said Corporation any notice of assignment or
reassignment before payment of the survival benefit/Maturity claim under the policy due on
I/We have not dealt with policy in any other way.
Dated at _____________________ this _________________ day of_________ 199
Signed by Shri/Smt. ________________________
in the presence of
Full Name : ____________________
Designation : __________________ Signature in full/short in English/
in Vernacular Present address on which
cheque is to be sent
Address : ______________________
Payment will be made ny Not negotiable – Account Payee Cheque on the Corporation’s Bankers
Payment by Demand Draft on any Bank or M.O. can be made only if the payee/s give/s a consent
letter on the following lines that the payment by Demand Draft or by M.O. be made to him/her/them at
his/her/their risk and responsibility and also agree/s to the bank/money made to him/her/them at
his/her/their risk and responsibility and also agree/s to the bank/money order charges being deducted
from the Policy moneys.
Place _______________________ Date ____________________
I/We hereby request the Life Insurance Corporation of India to make payment of the aforesaid
amount by a demand Draft/M.O. on the ________________________ Bank ___________________
at my/our risk and responsibility. I/We further agree to the Bank Charges/M.O charges being
deducted from the Policy moneys.
(1) ________________________________ (2) ________________________________
Signature/s of the Assure/claimants/s
(2) This discharge must be signed by the proposer/Life Assured and witnessed in English by any
English Knowing person provide he knows the Life Assured.
(3) Signature in Indian languages must have the English translations written beneath.
(4) Illiterate person who affix their thumb impression must have it identified by & attested by an
agent of the Corporation who is member of the club at the level of Divisional Manager’s club
and above, a Block Development Officer, a Gazetted Officer, Magistrate or an Officer or
Development Officer with atleast 3 years standing or a confirmed Development Officer
recruited from the agents who were D.M/B.M club members before joining or a Bank
Manager of the branches of STATE BANK OF INDIA or of one of the nationalised Banks.
(Provided the atteasting 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. The attesting official must make the following declaration under his signature.
Wife of/Widow of Shri _______________________________________________________________
has affixed his/her thumb marks in my presence after understanding the contents thereof.
Signature of the attesting official
seal of the Office
F. No. 5180 (M.D.O)
PAC-1,00,000 – 3/99
NOTE – In case of dispute in respect of interpretation of terms the English version shall stand valid.