Scribd Logo
Upload

Welcome to Scribd!

  • 184 views

    3801 Discharge Form Death Claim

    Uploaded by

    Sukomal Debnath
    This document is a discharge form for a death claim under a life insurance policy. [1] It acknowledges receipt of payment of the full claim amount to the nominee(s)/assignee(s)/legal representatives of the deceased policy holder. [2] It provides details of the sum assured, bonuses, deductions for unpaid premiums and loans, and the net claim amount. [3] The claimant(s) sign the form in the presence of a witness to confirm receipt of payment and discharge all claims related to the policy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    3801 Discharge Form Death Claim

    Uploaded by

    Sukomal Debnath
    184 views3 pages
    This document is a discharge form for a death claim under a life insurance policy. [1] It acknowledges receipt of payment of the full claim amount to the nominee(s)/assignee(s)/legal representatives of the deceased policy holder. [2] It provides details of the sum assured, bonuses, deductions for unpaid premiums and loans, and the net claim amount. [3] The claimant(s) sign the form in the presence of a witness to confirm receipt of payment and discharge all claims related to the policy.

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is a discharge form for a death claim under a life insurance policy. [1] It acknowledges receipt of payment of the full claim amount to the nominee(s)/assignee(s)/legal representatives of the deceased policy holder. [2] It provides details of the sum assured, bonuses, deductions for unpaid premiums and loans, and the net claim amount. [3] The claimant(s) sign the form in the presence of a witness to confirm receipt of payment and discharge all claims related to the policy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    184 views3 pages

    3801 Discharge Form Death Claim

    Uploaded by

    Sukomal Debnath
    This document is a discharge form for a death claim under a life insurance policy. [1] It acknowledges receipt of payment of the full claim amount to the nominee(s)/assignee(s)/legal representatives of the deceased policy holder. [2] It provides details of the sum assured, bonuses, deductions for unpaid premiums and loans, and the net claim amount. [3] The claimant(s) sign the form in the presence of a witness to confirm receipt of payment and discharge all claims related to the policy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    FORM NO.

    3801

    Divisional Office Branch Office

    DISCHARGE FOR DEATH CLAIM UNDER POLICY NO.

    Dated On the life of Shri/Smt

    I/We the nominee(s)/assignee(s)/legal representatives of the


    above named life assured by virtue of the nomination/assignment/legal evidence of title
    dated granted to me/us by the 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
    including the amount of Bonus, in full and final satisfaction and discharge of all my/our
    claims and demands under the above mentioned Policy on the life of the above mentioned
    person, who died on and which policy is hereby delivered upto the said Corporation to
    be cancelled :
    Sum Assured/Paid-up Value Rs .00
    Bonus Allotted/ Loyalty Additions Rs .00
    Interm Bonus Rs .00
    Final Additional Bonus Rs .00
    Difference of premium on account of
    overstatement of age Rs .00
    Refund of extra premium for Sex, DAB,
    EPDB and Occupation Rs .00
    Gross Claim Amount Rs .00
    Less
    Unpaid instalments of premium due in the
    Policy year of death Rs .00
    Late fee thereon Rs .00
    A.N.F Debt Rs .00
    Loan Rs .00
    Interest on Loan Rs .00
    Amount recoverable on account of
    Understatement of age Rs .00 Rs .00
    Others Rs .00 Rs .00
    Total Deductions Rs .00 Rs .00

    NET CLAIM AMOUNT Rs .00


    Dated at this day of

    Signed by Shri/Smt 1 Re.


    in the presence of * Revenue
    Stamp
    Signature of witness
    Full Name Signature of claimant/s
    Designation
    Address

    Fathers Name :
    Husband Name :
    Address :

    Notes :

    (1) Payment will be made by a crossed and order cheque, if payment is desired by M.O
    (Net upto Rs. 1000/- only ) 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 own
    risk and responsibility. I/We further agree to the M.O. Commission/Bank Charges
    being deducted from the claim amount .

    (Signature of Claimant/s)

    (2) This form must be completed before (1) an advocate, (2) an Agent of the Corporation
    (who is a member of an Agents club at the level of Divisional Manager’s club or
    above), (3) a Bank Manager, (4) a Block Development Officer, (5) a Commissioner of
    Oaths, (6) 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 atleast 3 years standing (12)
    A confirmed Development Officer recruited from the Agents, who were DM or BM
    Club Members before joining (13) A Development Officer recruited from agents who
    were ZM or Chairman’s club members before joining (14) President of a Village
    Panchayat or Local Body.

    (3) If more than one person have signed the Discharge Form, the names of all the persons
    should be stated.
    (4) A female when signing, must add her father’s as well as her husband’s name after her
    own, describing herself as a daughter of Shri and wife/widow of shri
    (5) “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 Corporation
    (who is a member of the club at the level of Divisional Manager’s club and above), a
    Block Development Officer, a Magistrate, or an Officer or Development Officer (with
    at least 3 years’ service as Development Officer) of LIC or a Bank Manager of Branch
    of State Bank of India or of one of the nationalized banks (provided the attesting
    Branch 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
    Government. Where thumb marks are affixed, the attesting official must make the
    following signature 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.”

    Place Date

    We hereby authorize and request the Life Insurance Corporation of India to pay the
    within mentioned amount of Rs. .00 to Shri/Smt .

    Signed by the parties within mentioned in the (1)


    presence of :-
    (2)
    Witness
    Signature (3)

    (Signature in Full)

    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 authorised party.

    (Signature of Witness)

    You might also like