To

The sr. Branch Manager

L.I.C Of India

Bahinda

Dear sir,

REG.—INTIMATION OF DEATH CLAIM

POLICY NO. ____________________________________________________

NAME OF L. A. __________________________________________________

RELATION WITH L. A. _____________________________________________

DATE OF DEATH ______________________________________________

CAUSE OF DEATH _______________________________________________

PLACE OF DEATH. ________________________________________________

IT IS INFORMED THAT ABOVE SAID POLICY HOLDER DIED AND SHE WAS INSURED
WITH YOUR OFFICE ( L.I.C OF INDIA ) KINDLY ISSUE ME CLAIM FORMS

YOURS FAITHFULLY

SIGNATURE OF CLAIMENT