‘slay - orga — ANNEXURE - 1 wa ®. 3783 (qurea) ‘Bra a HHH w, F, No.3783 (Rev.) (seh. ara FH &) CLAIM FORM ‘A’ sre ferry Mans! Deision “1 ore erates Branch Office. -SRERTA wer / ER BTW / CLAIMANT'S STATEMENT. (ro ene ene erie FRONT aR eA) (ene 4 AR oF TY rE AAR I HT TE) (To be filled in by the person legally entitled to the Policy moneys) (ad ook TST ere, TAR ria eeTA. Sear ig far Var hare TTR ATT.) (SR Ser ere fered one Tee eet 4 AA OTA aeG| em & Fer, forg a aa see OT a eo Al BH oT Tah) (All answer to be filled in legibly. Answers must be given in words. Strokes of the pen or dots or dashes cannot be accepted as replies) ar agers B.A (q@re gi ia) 3 atic, = 3 ha wea afer (aes aor a fered) a ft aia trons a a a In Connection with claim under policy No. —-—__________ for Rs. on the life of. (Insert full name of the deceased) Rata sent area ater Geter Part ae, Heh & aE & WTF Fes ae sa Zl |, as the claimant under the policy make the following statement: 1) artanrdaeh anfett - aren & fare H flawt- Particulars regarding the claimant: |) emer ara / ardare a1 ar / Name of the Claimant. i) wa/ mg /Age il) RAAT. / Tel. No. iv) Ter/ Get /Address, vere are ae aa dite 3 wry Relationship to the deceased life assured vi) Sfertten eater earicaren roe / Fa: ae, VAGAAAM, Perea, were, Reaet ia ere ate ae rs trier a a fg arg rer, ta a, sh, Per, ee, =a a ‘Renita Nature of Title under which the claim for policy money is submitted viz : Nominee, Assignee, Executor, Administrator, Trustee of Beneficiary 2) Fa atta aafrsiah aaeite ‘Rattan & Faved aT Particulars regarding the deceased life assured. Ah sere ShriSmt. 1), ier eave ee Bem ter dag ae Place of death of the life assured (PTO)ii) yey Reales / Ry Af / Date of death. arash Petre tas / ey ar dts wT / Exact time of death alg / ar arsen re: ERE: AM / PM. ii) Be Ar aa ae Be wr den sh arg Age of if assured at death iv) sae SoM FET cafe et aay Duration of las ness. Immediate cause of death vi) Sie eafeeren sree rere en a sift ATT Last occupation of the life assured vii) Sifter eafeeren sree Te er oF sffer aT Last address of the life assured vi) rer af et at rer Rev aT RTA Full name of deceased's father 3) 5) ye Safer TET SA MRA maf ace Be Arar oe area Safer & fave a fear Particulars regarding the other Policies on the life of deceased : Policy No. | SumAssured | Name of issuing Office & Servicing Branch Siert 2oran/ Sat eT ‘ifort a. Star | wrt ara / ort ae are ert aeratt ‘preter en Sar IAT wT A sare Reta ore ot Fae Date of Commencement Whether with Double Accident or Extended Disability Benefits {| a) Tete Se aeearacereh HH et APT ere aoeaT Sehr? Bae 9 eae She 7 aH wa Gea rors wa TH A? When did the deceased first complain of being not in usual good health? b) SmaSar aa Sear START ese es ara feast Rrra BE Nature of illness then complained IaCoT STOTT GTA OTT terse feterewtA a saa Se 5 wr PAPC Be aT | ‘The names of medical attendants during the last illness.ae 6. Fem ae asia ater een Seren, aren As Serahta Paterna Ta ani qe. ete Ferment aTaIys Teo Serer THT wae anf cute fetter Fer. fae ai ae & aver yer 4 form Pafeoceeet & serref ferem srerar Pease aerg BY, Tre aA Ste ga ce eee Bs aA RRrewrTT ‘sem fang 1g seraet she ere FA an fae arg Names and addresses of the doctors consulted during the last three years stating against each name the complaint for which he was consulted and the date or dates thereof. ee Cera FA Paeoeere | Serer aia aie aT oe aa eer emg SA a Fe ar AA Fefascereey ar orererct & rr ote a Rraraa & fret Date or Dates of consultation Name of the Doctor or Hospital Nature of complaint and address 1 2 3. hus Em Srey eh RANT Bae dae Rar ate aac ee ta. a eS eet exe aoe fo or fra SW wh wet & ae wh oe S Ta .do hereby declare thal a salorenis rca Teoh obove are Fun Teach end every Teepect ort rere ene SATE EI aH ATA aT EA eT et AT eae err FHCRC aT STMT HTT TAA AT TRH HA HLTH SA TS SOAR A AN TTA START, FT TFA GET AN RS HAT STI AY ATT aI STA DATA ST CAT TIAA PTY SARITA HAN FT TOT ON HT SATA MTA A APSA TT domme ar vier atte PERCE) wr ee rere BEA one A Aeris car arafery care arate Teorey Pat STAY ‘aera eatery as ava A aTgeT Be aT. ‘ee oh Fee, ere, HR ar Rear sve ret sees HT Teas TRY eT A APT aT HTT BY PAT 3 STIR oe feet cafes oA ts See oe re BE SATEEN a eT aA & fry ahat aeea ay at A Taga Sa Patera ar sree gH, HTT sear phere a Prt et er fe itera ae rer, renee Fr eae eer oh A ee a TAT Seva Ha rer Hae aT A TA Be TT aT mT HA wy, es Pe, era retort he FARR ere a fee AM a ay STAT wma! "Notwithstanding the provisions of any law, usage, custom or convention forthe time being in force prohibiting any physician or Hospital from divulging any knowledge or information acquired by him/them in attending upon or examining a person on the ground of secrecy. | hereby authorise the physician or Hospital who has attended upon or examined or treated the aforesaid deceased life assured for any ailment oiliness to divulge any knowledge or information regarding the deceased state of health which helthey may have acquired whether before or after the Policy was issued by the Corporation, to the Corporation, its offices and legal advisors or in court of law. feat ai-2000 Taree wr fete e-2000 Famer eh Declare at this —___dayof______20 _ before me. ardent werent / seroaret Prenety -” waar & semen / sis & Fre Signature / Thumb impression of the claimant Ber / eA ie giare/ quam Dectare at, this. Full Name nnn amine Ai 28. ATE ae BI / 3 Designation. cr 2000 HR aerate ‘Tat / Fa Address. Dated at. this Day of 20 __ before me Remit w/ Tel. No. ‘ereftarerstt eararet / ret & eee. Signature of Witness (ero)whe er: 8 uray gehen gti earns BIA TE (1) eee (2) metre ele (ot Rees wees wi pa cee ae ‘aren ee rte ENA) (3) as Hore (4) re Rrra (5) eve sTgar (6) Stax (7) ARP sire (8) reer Reereraren TEMES (9) HoT Se ATR fer reat T-AS AT (WH MTA A-AER eZ) (10) aren (11) gh re ce ten bar pas a ta ee ere ene ra afte eres ar ear eS woien Serer Beer ora, Moi Peete sn erat rete Rares ent fr (12) smear fer ens eeetar sree, feeroht sg ear Frias A feet cas A ener fet een Vr eafey (1) aifracrar (2) Pmt wr aftpal (ot User eae era aT ‘TAR GH & saftrarat Tera ar BRT Bl) (3) dey wderes (4) meats faeore safest (5) ese agar (6) Pfr (7) ‘crore afer (8) sea TERT wT GROTON (9) Hw wT fear Ar we Tenor (wea sre El) (10) wraiftraontt (11) Frm ar aaftrert, sterar sftiares ar Facer aiftrert (fore fecore siftrertt & er a or a or 4 adi oe Ya FA) a, 3 te ert aw afeaisl § Agar ot iw, a aw. aT. oem aoa Weel A. ot. oT fPegaer Ye cet (1.2) mH eee rere ener Freer a reat | NOTE : This form must be completed before (1) An Advocate (2) An Agent of the Corporation (who is a member of the club at the level of Divisional Manager's Club or above), (3) a Bank Manager, (4) a Block Development Officer, (6) a Commissioner of Oaths, (6) a Doctor, (7) a Gazetted Officer, (8) a Head Master of High School, (9) a Head Post Master or Department Sub-Post Master (but not a Branch Post Master) (10) a Magistrate, (11) an Officer or Development Officer of atleast 5 years standing or confirmed Development Officer recruited from Agents who were Z.M. or Chairman's club member before joining (12) President of a Village Panchayat or Local Board. oe chorea eenfte / ory arts werent eh ante Rar sivsaren Ser Tefen set aR MreflaRT get evo wae eh Te, ‘af Ehaorevat Fave sree ray A eeerere acer & a ofS aot Pens ere & at ee ay Prefeattet chon oe oA BTA AT fey! IF THE DECLARANT SIGNS IN VERNACULAR OR AFFIXES THUMB IMPRESSION, THE WITNESS SHOULD ALSO SIGN THE FOLLOWING DECLARATION. = owe mB Hae Shere ener ae SET Re aT PH ea FA a Ae aT Fa aT ATI A SHITE eh CRT aT.” se eae 85 eH ae hep Bey we a re Rea ee TAH aN A a a So ae a aah oe ore eecrer HAG eT sige Pr Tee CERTIFIED THAT THE CONTENTS OF THIS FORM WERE EXPLAINED TO THE DECLARANT OF VERNACULAR AND HE / SHE HAS AFFIXED HIS / HER SIGNATURE / THUMB IMPRESSION HERE TO AFTER FULLY UNDERSTANDING THE eae / een / Signature pt aa/ qr aR/ Full Name ¥/ 5@/ Designation wra/ at / Address geet / gas / Tel. No. Be Sera woe Pere aque Ga ondchar See mer eS OTE, ser Jolt. F.No. 3783 (Rev) fa: gama argh aren} Bey ssh ss @ ale a eT ‘JA110000 708-2016 Note = In case of dispute in respect of interpretation of terms the English version shall stand vali.