Claim Application form

From Date:
____________________________
____________________________
____________________________
____________________________

To,
The Branch Manager
New India Co-operative Bank Ltd,
_____________________ Branch

Sub: Claim settlement of SB/CA/TD/locker no. __________________________in the

name of __________________________________________________________
Claimant’s name: _______________________________________________________

Dear Sir,
I/We ___________________________________________________________________________________
would like to inform the bank about the demise of ____________________________________________
on __________________________ having SB/CA/TD/Locker no. mentioned above in your branch.

Further:
1. The nominee(s)/survivor(s)/legal heirs(s) to the above account/locker are

Sr. No. Name Age Relationship

(to be filled only if there are minor nominees/legal heirs)

Minor Minor Minor
I II III
Name of minor
Name of guardian
Guardian type
Relationship with
guardian
Guardian's
signature
(if guardian is appointed by court then duly attested court order/letter of administration should be attached)
2. Deceased has died testate/intestate

3. The claim may be settled as per

Nomination Probated Will

Succession certificate Letter of administration

As per bank's policy, in absence of above

4. The claim amount/contents of the locker should be given to:

(Please tick as applicable)

a. As per Nomination

b. As per instructions in succession certificate/Probated Will/Letter of administration

c. ___________________________________________________
not more than one claimant who is authorized by legal
heirs and consent of which has been given hereunder vide their signature:

Sr. No. Name (as mentioned in point 1 ) Signature

5. Details of claimant (should be as per point 4 above):

Claimant I Claimant I Claimant I

Affix passport size Affix passport size Affix passport size

photograph photograph photograph

(Sign across the (Sign across the (Sign across the

photo) photo) photo)

Signature of the Signature of the Signature of the

claimant claimant claimant
6. Kindly settle the claim by

Paying in cash Credit to my/our SB/CA/OD A/c no._______________________

Issuing PayOrder/DD Open & Credit the amount in minor’s a/c

NEFT/RTGS to my/our SB/CA a/c no. ________________________________________ with

__________________________________ bank, ________________________branch bearing
IFSC code: ______________________________

Handover the contents to ___________________________________________________ as

per point 4 above

7. List of documents submitted:

(Please tick as applicable. For list of applicable documents please seek advice from Bank's staff)

Identity proof of claimant

Address proof of claimant

Death proof of deceased

Third party declaration

Cancelled cheque of beneficiary in case of NEFT/RTGS payment

Other Please specify _____________________

I/We hereby solemnly affirm that the information given above is true and correct to the best of
my/our knowledge and belief. Any additional papers required by the Bank for settlement of the
subject claim will be submitted.

Yours Sincerely,

_____________________
Signature of Claimant(s)

FOR OFFICE USE

Claim processed by: _________________________ Processing date: _____________________

Processor’s remarks: ____________________________________________________________

_____________________________________Signature: _________________________________

Claim sanctioned by: _______________________ Sanction date: _________________________

Sanctioning authority’s remarks: ___________________________________________________

______________________________________Signature: ________________________________
 Declaration for claim settled in favour of a minor

I, ________________________________________________ natural/legal

guardian of ____________________________________________________

hereby certify that, amount/contents of locker received from New India Co-

op. Bank Ltd towards claim settlement against the a/c/locker of Late

Shri/Smt._____________________________________________ vide claim

application dated ____________ will be utilized for the benefit of the minor

only.

Signature: _______________________

Name : _______________________

(Natural / Legal Guardian)

 CLAIM RECEIPT

Received an amount of Rs. _________________/- (Rupees

________________________________________________________only)

from New India Co-operative Bank Ltd. towards the claim settlement of

late ______________________________ wide the claim application dated

___________

Claimant Name: Sign across

the revenue
stamp
Place:
Date:

Claimant’s signature
 Undertaking for claim settlement
To,

The Branch Manager,

New India Co-op. Bank Ltd.,
__________________________ branch.

Sub: Claim settlement of A/c no.________________ in the name of ____________________________

Dear Sir,

I/We _______________________________________________________________________________ the

legal heirs of the deceased late Shri./Smt. _____________________________________________ having
A/c no.______________________________________ with your bank, request you to settle the claim
amount of Rs.__________________ (Rupees _________________________________________ only) in
favour of Shri./Smt. ____________________________________________ (claimant) without production
of Probated Will/Letter of Administration/Succession Certificate.

We do hereby for myself/ourselves and my/our heirs, legal representatives, executors and
administrators, jointly & severally UNDERTAKE AND AGREE to indemnify you and your successors and
assign against all claims, demands, proceedings, losses, damages, charges and expenses which may
be raised against or incurred by you by reasons or in consequence of you having agreed to pay/or
paying the said sum as aforesaid to Shri./Smt. __________________________________ (claimant)

Yours Sincerely,

(To be signed by all legal heirs including claimant)

Sr. No. Name Relationship with deceased Signature

Place:

Date:
 INDEMNITY BOND
THIS DEED OF INDEMNITY executed at Mumbai, on this day of ____________________________ by
Name of the legal heir age year, resides at
1) ______________________________________________________________________________________

_______________________________________________________________________________________
Name of the legal heir age year, resides at
2) _____________________________________________________________________________________

_______________________________________________________________________________________
Name of the legal heir age year, resides at
3) _____________________________________________________________________________________

_______________________________________________________________________________________

4) Name of the legal heir age year, resides at

_______________________________________________________________________________________

_______________________________________________________________________________________

Name of the legal heir age year, resides at

5) _____________________________________________________________________________________

_______________________________________________________________________________________

(hereinafter called the OBLIGATOR which expression shall unless executed by or repugnant to the
context include their respective heirs, executors, administrators and legal representatives) of the ONE
PART do hereby bind ourselves jointly and severally to pay to and indemnify the NEW INDIA CO-
OPERATIVE BANK LTD., a bank registered under Multi State Co-op. Societies Act, 2002, having
Corporate Office at Anant Vishram Nagvekar Marg, Prabhadevi, Worli, Mumbai – 400 025 and its
Branch at _________________________ (hereinafter called the BANK which expression shall unless
executed by or repugnant to the context include its successors and assigns) of the SECOND PART in
the manner hereinafter appearing.

WHEREAS

1. The Late ________________________________________________ residing at

_____________________________________________________________________________ (hereinafter
referred to as THE DECEASED) had a sum of Rs.______________________/- to his credit under A/c.
No. _______________________________ /contents of locker no _________________with the Branch of
the Bank.

2. The deceased died intestate on __________________ and the contents of above locker no. /the
deposit has now become payable with the interest to the legal heirs of the deceased. The obligator
claim to be entitled to the said payment of monies as and when each becomes due, as heir/s of the
deceased but not obtained letter of administrator or a succession letter of heir ship to the assets and
effects of the deceased.

3. The obligator no 1 vide his/her claim application dated ________________ has claimed the amount
standing in the name of the deceased in the various deposit accounts/possession of the contents in the
locker standing in the name of the deceased. The other obligators have also given their consent in
favour of the obligator no 1 to claim the assets standing the name of the deceased to the bank.

4. On the basis of the claim application received from obligator no 1 and the consent received from
other obligators, the Bank on _______________ (date) granted the claim in favour of obligator no 1.
5. Accordingly the Bank is giving contents of the locker/paying amount of Rs __________________ /-
(Rupees___________________________________________________________________________) being
the amount of balance together with interest upto date standing in the name of the deceased
in various deposit accounts as mentioned in the claim application to the claimant/obligator no
1 Mr./Mrs________________________________________.

NOW THIS DEED OF INDEMNITY WITNESSETH that consideration of the Bank agreeing to giving
contents of locker/payment of the monies as and when they become due together with interest due
thereon the obligator jointly or severally does/do hereby undertake to indemnify and always keep
indemnified the Bank and its Officer, servants or agents in the event of any claim being made by any
person against Bank & its officers, servants or agents with respect to the claim settlement whole or in
part or with respect to any payment in respect thereof including interest and agree to forthwith refund
on demand to the said Bank the sum together with the interest and the obligator each of them shall
otherwise keep indemnified and saved the Bank and its officers and servants or agents harmless from
all liabilities, actions, suits and other expenses whatsoever, which shall may at time or times
hereafter be brought by reason of payment of aforesaid sum in respect of any claim arising there
from.

IN WITNESS WHEREOF the parties hereunto set their respective hands on the ______ day of _________ 20

Name Signature
1) ______________________________________________________________________________________

Name Signature
2)______________________________________________________________________________________

Name Signature
3)______________________________________________________________________________________

Name Signature
4)______________________________________________________________________________________

Name Signature
5)______________________________________________________________________________________

In the presence of:

Name Signature
1)______________________________________________________________________________________
Address
_______________________________________________________________________________________

Name Signature
2)______________________________________________________________________________________
Name
Name
Name
Address Signature Signature
Signature
______________________________________________________________________________________

Sign & Seal of the Notary

Date:

Sr. No:
 THIRD PARTY DECLARATION FORM

First name Middle name Last name

I, ________________________________________________________________________ residing
at ________________________________________________________________________________
__________________________________________________________________________________
do hereby declare and state as follows:

I know the deceased _______________________________________ for the last ________ years,

residing at ________________________________________________________________________
_______________________________________________________________________________

He/she died on __________________ at _____________________leaving behind the following

dd-mm-yy Place
family members:

Sr. No. Name of the family members Age Relationship with deceased

I hereby solemnly affirm that the information given above is true and correct to the best of my
knowledge and belief.

Signature:

Place: Date:

Encl: Identity & Address proof