Form No.

3801

LIC
LIFE INSURANCE CORPORATION OF INDIA

Bangalore Division 1

Discharge of Policy No.

/ t (Hd)

On the life of..

I/We (Name &Relationship)
of the above
by virtue
named ...

of Nomination /Assignment / Title Holding

granted to me/us by the Text ofthe Policy under policy
do hereby acknowledge receipt from the above mentioned Corporation the
date
Sum of RUPEES
including the amount of Bonus in full satisfaction and discharge of all my/our claims and demands under
the above policy on the Life of therein mentioned who

died on ...... and which policy is hereby delivered unto

the said corporation to be cancelled.
¥Y/SUMASSURED F./Rs

aH/BONUS 6./Rs

siaftHaH/Interim Bonus 5./Rs

sif4 3fafteaH/Final Additional Bonus F,/Rs.

Dif. of Prem.on account of age having been overstated F./Rs

Loyalty Additions ./Rs...

F./Rs
Refund ofextra premium for sex/DAB and EPDB/Occupation
Gross CIf F./Rs..
 Yh 4T/GROSS F./Rs
h4 /LESS

Unpaid Instalments of
premium due in
the policy year of death: 5./Rs
faria yrh /Late Fee F./Rs
U/Loan F./Rs
/Interest F./Rs

Diff. of sum assured & Bonus

on account of age having
been understand F,/Rs .. ,/Rs

NET AMOUNT PAYABLE

F./Rs
fioi (RT) Dated at 3A|S this.. fcaH day of. H/Month 202.....

Signature of Witness:
1 Rupee
Revenue
(as per instruction No. 1) Stamp
I4/Name T HT (Signature in full)
YG1H/Designation:
YGI/Address In case of lady please mention husband name

fyI H/Daughter of

Please read carefully the instructions before completing this Discharge Form
1) This form must be completed before (1)AnAdvocate (2) An Agent of the Corporation who is a member
of the club at the level of Divisional Manager's Club and above (3) a Bank Manager (4) a Block
Development Officer (5) aCommissioner of Oaths (6) a Doctor (7) aGazetted Officer (8) a Head Master
of a High School (9) AHead Postmaster of Departmental Sub-Post Master (but a Branch Post Master)
(10) a Magistrate (11) an Officer or Development Officer of atleast 3years standing or confirmed
Development Officer recruited from the Agents who were D.M. or B.M. Club Members before joining or
Development Officer recruited from Agents who were Z.M. or Chairman's Club Members before joining
(12) President ofaVillage Panchayat or Local Board.
2) Ifmore than one person have signed the discharge form, the name of allthe person should be stated.
3) Signatures in VERNACULAR must have their English transactions written beneath.
4) Afemale when signing must add her father's as well as her husband's name after her own,
describing
herself as daughter of Sri ...

and wifewidow of Sri.

 5) In case the claimant affxes thumb impression, the thumb impression must be atfested by an Agent of
the Corporation (who is a member of the cub at the level of Divisional Manager's Club and above), a
Block Development Offirer GAzetted Ofcer, Magistrate, Or an Officer or Development Officer (with at
least 3 years senvice As Development Officer) of LC or a Bank Manager of Branch of State Bank of India
or of one of the Nationalised Benks (orovided the attesting Bank Manager signs after affixing an Official
Rubber Stamp giving his nAme and designation asalso the name and addressof the Bank where he is
working) or the Principel /Head Master of alocal High School or Higher Secondary School run by
GOVERNMENT Where thumb marks are affixed, the attesting official must make the following
decleration under his signature.
Sri/Smt Son/Daughter
and wife/widow
of Shi.
of Sri
has affixed his /her thumb marks in my

presence, after understanding the content thereof

BANKA/C
6) PLEASE FILL IN THE NEFT ROOM ON PAGE4 TO MAKE PAYMENT TO YOUR
NOTE OF AUTHORITY

Place:
Date

1/ We hereby authorise and request LIFE INSURANCE CORPORATION OF INDIA to pay the within
mentioned Rs.
to

Signed by the parties

Within mentioned in the presence of

Magistrate or Justice of Peaceora Gazetted

officer or a Block Development Officer or a Class/
Officer of the Corporation provided he is fully
satisfied about the identity of the executant (s)

Signature in full

"ihereby certity that the contents of the NOTE OF AUTHORITYwere explained by me in VERNACULAR to
and he/she/they has/have agreed
topayment being made to
the parties authorised.

Magistrate or Justice of Peace or a Gazetted

Officer or aBlock Development officer or a Class-1
Officer of the Corporation provided he is fully
satisfied about the identify of the claimant

*This endorsement required to be completed and signed by the attesting Magistrate or Justice ofpeace or a
Block Development Officer oraClass 1 Officer of the Corporation when the note of Authoritycompleted by
an illiterate or VERNACULAR knowina person.
 NATIONAL ELECTRONIC FUNDS TRANSFER - MANDATE FORM

To.
LIFE INSURANCE CORPORATION OFINDIA
Branch

Sub: Receipt of policy payment through NEFT.

Iam giving below the details of myBank account for receiving policy payment through NEr.
(1) Policy No/s.

Name ofclaimant:

(2) Bank Name:

(3) Bank Branch Address :
(4) Account Type: Savings / Current /Cash Credit/NRI :
(5) Account No.

(Bank account number should be written from left to right)

(6) IFS Code:

(7) Mobile Number:

(8) E-Mail ID:

(9) Are you willing to Receive SMS/E-mail, on matters related to your LICPolicies; *
Yes No

Ihave enclosed the following document to this effect (Please appropriate item)
A Cancelled cheque leaf
B Ifcheque is not having the name of bank holder than Photo copy of the page
ofBank pass book containing details of Bankaccount number, IFS Code

Signature of the claimant Date:

(Incase of change in Bank details, please fill this mandate form again and submit the same to Our
"If your answer to Q No.9 is 'Yes', then we will be able to send youa
Branch Office)
message when LIC transfers money to your
Account through NEFT.This message willcontain the UTR (Unique Transaction Reference) number
used to make any enquiry regarding the which can be
payment.
 IRDA
7 fo e itoesd to obiirn tho fatNa da sti: of danth of ifo xeetfod &
rafralrx of tho aimnt for go &Cpdète tolomert ofcatns
par IRIDA Ragnlwhonn
() DETAL3OF THE UFË ASSURR5D LxBs

Servicieg BO.
DaBoof Dath:
3) xo of Doxtb:
4) Cao of doalth:
5) Tins of dozt
6) Whotb hoepilzisd
7)Nmo of tbo Horitzl &plo

9)Pticulm of Mmetidaim InesnaPoici

2oj Pathcala rgzrdigptho Irenacooliosbld by ihoeeoedhudor

2iahgedópto thé do
DAoaliaa to bopgt tillcottrteat af

NAME
DOOR NO.

) Reideatizl / offico l catl aons t

9 IIENHEHCATION OF TH5CLAIMANT (n co of ilhtorade)
sdostified by.

SIGNATURE OFT5 CLAIMANT

 Form No 3783 (A)

LIC Branch Ofice

CLAIMANT'S STATEMENT
(To be Riled in the by the Persnn, legally entited to the Poficy Moneys)
LIFE NSURANCE CORIPORATON NDIA (Al answers to be itled in ligibly, Answers must be given in words
Strokes of the pen or dota or dashes cannof be accepled as repairs)
Banaaloe Divteion
in the life of
for Rs
In connection With the im under ocy No (insert Fu#

name the doeNA

Ias fhe clemart UYder the pocy make the following statement
1
Particulars reg Ardingthe Clamant
() Nameo the Clamant
() Age
(n) (a) Address

(b)Telephone No
(rv) Relationship to the deceased life assured
(v) Nature of tile Under which the claim for policy
money is submitted Viz Nominee, Assignee,
Executor, Administrator Trustee or Beneficiary
2. Particulars regarding the deceased life assured: Shri / smt.
() Place Date of the lite assured:
(1) Date of Birth: Exact time of death AMW PM
(m) Age of the assured at death
(iv) Duration of last illness
(v) Immediate cause of death
(vi) Last occupation of the lite assured
(vi) Last address of the lite assured
(vi) Full narne of the deceased's lather
3. Particulars regardingother policies of the deceased
Date of Whether with Double Accident
Policy No. Sum asSured Name of issuing office OR Extended Disability Benefits
Commencement

do hereby declare that the statement made made herein above is true in each and every
I, any
respect. Not with standing the provisions of any law, uságe, custom or convention for the time being in force prohibiting
Physician or Hosptal from divulging any knowledge or information acquired by him/them in attending upon or examining a person
on the ground of secrecy, Ihereby authorise any knowledge or information
regarding the deceased's stte of health which he /they
corporation, to the corporation, its officer's and legal
may have acquired whether before or after the policy was issued by the
adviser's or in anycout of law. 20 before me
Declared at. . . . . . . ..
this day of
signature of witness with seal
Signature Thumb impression of the claimant
Designation
Address' t Full Name.
Tel. No.
(who is a member of an Agents club at
Note: Thislorm must be completed before (1) an advoçate, (2) An Agent of the Corporation Officer, (5) a commissioner of Oaths.
Block Development
the level o Divisional Manger's club or above), (3) aBank Manager, (4) a(9) a Head Post master or Departmental Sub-post Master
(6) aDocor, (7) a Gazetted Oficer, (8) a Head Maser of a High School,
Officer or Development Officer of atleast 3 years standing
but not a Branch post Master, (10) aMagistrate, (11) An were DM or BM club Member before Joining
(12) A confirmed Development Oficer recruited from the Agents , who
agents who were ZM or Chairman's club memebers before joining . (14) President ol
(13) ADevelopment Otficer recruited trom
village Panchayath / Local Body.
and the gaps filled in at his
CERTIFIEDTHATContents of this Certificate were explained to the declarant in a Regional Language
dictation

Signature of witness: