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NAGPUR DIVISION
(Established by th6 Life lnsurance Corporation Act, '1956)
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INT. NO,

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Discharge of Policy No. dt.
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life of maturing/due on
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the Life assured/assignee(s)/Trustee
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acknowledge receipt from the Life lnsurance Corporation of lndia of the sum of
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Rupees frrmq wtatowEfli M <ror* qwr rffi"q orq{ Eqr fiqnn{Eiqrfrm qr$ $d Ed
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6qlt Ed Si qiqt d Wf ge t lthe gross amount of claim in full and final satisfaction and Oisc'narge of all my/our ctaims
rd demands in respect of the following payments under the above policy in terms of the policy contract.
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lA/y'ehereby declare that liWe have not served on any office of the Life lnsurance Corporation of lndia any notice of assignment or @
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reassignment in respect of the above POLICY/IES except those, if any, already registered by the Life lnsurance Corp'oration of o
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lndia or the lnsurer who issued the above POLICY/IES nor shall l/We serve on any office oithe said Corporation any notice of so
assignment or reassignment before payment of the survival benefiVMaturity claini under the policy due on (})
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lANe have not dealt with Policy in any other way.

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Policy is hereby delivered to the said corporation for cancellation/endorsement.

ft-ci-6 ern fr{io qraqtrcr 20, 20
Dated at this day of 20
rcmfua$7ffi Signed by Shri/Smt. +
frwtut q,lscfurfrii in the presence of *
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i re of witness
mfr'<ffin$ryi+a qr*orfo+tq Particulars of witness
Wqrt Full Name
gerr< Designation
qcr Address
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Mobile No. 6o'o-<x7<rffil d tt idtr edq t mmurr
E-mail Address Giffi/qriRro qrqTt)
Bank Arlc. No. Name of Bank (Signature of the claimanUs
Saving/Current AJc : IFS Code in full & short in Englishtuernacular)