ĒĂąŪđĎēĉĒčĀ

Claim Voucher (Pay for SB/Surrender/Loan/Maturity/Death/Supplementary)

ąēćđčáƠđȭþÿƟđąĊē(Policy Related Information) ąēćđƣđĎĘïĉąƟĒǏñþþÿƟđąĊē(Policyholder's Personal Information)

ăĒĊĒčĂá Policy No.) SLICL-P-0000089802 ĂđćíLJïđĂđ(Name & Address)Md. Rezaul Hassan Sharif - V/RD
-0720
- A/22, Road-2, Block A Chandgaon Housing
ąēćđ˝˙ĉþđĒĉð Commencement Date) 16/07/2020 ąĠč
P.O. - Chakbazar
(Age)
ăĒĉïɤĂáíĺćĠđĀ(Table & Term) 3 - 10 P.S. - Chandgaon
DIST - Chittagong
47
ĒƵĒćĠđćƵĀđĂăȝĒþ(Mode of Payment) Yearly
MOB -1992022908
ăĒĊĒčãăċĂ Policy Option) C
ąĖĒíƵđăïąēćđąĖþĒċ˝(Stipend Holder/Assured Child): 0
ąđĒČŪïĺăĂċĂąĖĒí Yearly Pension/Annuity) 0
ãĒþĒĉǏċþŪĈĒĀÿđĘï(Extra Condition -if any): Accepted at O/R.
čĎĘĈđñēąēćđ Supplementary Coverage) 0
ąēćđãáï Sum Assured) 1,000,000 ïÿđĠ(In Word): Taka Ten Lakh Only

ĂĒćĂē Nominee):Kamrun Nessa ąĠč Age):40 čɑïŪ(Relation): Wife ãáċēĀđĒĉʲ Percent of Share): 100

čáĒǘȼĒĎčđąĒąąĉýē(Calculation in brief in Taka)

ëčĒąĀđąē(Claim of Survival Benefit) čćăŪĘýĉĀđąē(Claim of Surrender) éĘýĉĀđąē(Claim of Loan)

ĒïĒʅĂá(Installment No.) 2 čćăŪýćĕĊƟ(Surrender Value) 0 éĘýĉäáï(Loan Amount)
ùđïđ(Taka) 150,000 ĊĆƟđáċ(Profit) 0 čđĒĆŪčôđöŪ(Service Charge)
ĺćđù(Total) 150,000 ĺćđù(Total) 0 ĺćđù(Total)
ćđĒčïĒïĒʅ(Monthly Install.)
ĺćĠđĘĀđíĉĀđąē(Claim of Maturity) ćĖþƟĀđąē(Claim of Death) ąēćđƣđĎĘïĉĀđĠčćĕĎ(Liabilities of Policyholder)
ăĕýŪąēćđãáï(Full Sum Assured) 0 ăĕýŪąēćđãáï(Full Sum Assured) 0 ąĘïĠđĒƵĒćĠđć(Outstanding Premium) 0
čɑđĒĀþąēćđãáï(Paid Up Amount) 0 čɑđĒĀþąēćđãáï(Paid Up Amount) 0 ąĘïĠđéý(Outstanding Loan) 0
ĊĆƟđáċ(Profit) 0 ĊĆƟđáċ(Profit) 0 ĒąĊ˘ćđ˝Ċ(Late Fee) 0
ĺćđù(Total) 0 ĺćđù(Total) 0 ăĒĉĘċđĒāþëčĒą(Paid SB/Pension/Stipend)
ĺćđù(Total) 0
ĺăĂċĂ(Pension) (Stipend) čĎĘĈđñēąēćđ(Supplementary Claim) 0
ĒïĒʅĂá(Installment No.) 0 ĒïĒʅĂá(Installment No.) 0 ãĒþĒĉǏöćđ(Suspense Premium) 0
ćđĒčïąđĒČŪïĒïĒʅĉăĒĉćđĂ ćđĒčïąđĒČŪïĒïĒʅĉăĒĉćđĂ
0 0 çƄčïĉ(Tax) 0
(Amount) (Amount)
ĺćđùĀđĠãáï Total Liabilities
ĺćđùĀđąēãáï(Total Claim Amount) 150,000 0 ƵđăƟ(Payable) 150,000
Amount)

ąēćđƣđĎïĂĒćĂēĉąƟđáĘïĉĒĎčđąčáƠđȭþÿƟđąĊē(Bank Details of Policyholder/Nominee)

ąƟđáïĒĎčđąāđĉēĉĂđć(Name of Account Holder)

ĒĎčđĘąĉƵïĖĒþ(Account Type) ôĊĒþčǹĠē(CA/SB): ãĂĊđåĂčĂđþĂē(Online/Manual):

ĒĎčđąâĉ(Account Number) ąƟđáĘïĉĂđć(Name of Bank)

ċđðđĉĂđć(Branch Name) ąƟđáĘïĉLJïđĂđ(Bank Address)

Revenue Stamp
----------------------------------------------------------- Tk. 10/-

(Signature of Policyholder/Nominee) (Name of Policyholder/Nominee)

ĒƵĠćĘĎđĀĠ
ä̧čđĊđćĔ
äĊđåʛćĂćɾđĉÞçĘɨĒðþąēćđăĘëĉċþŪđĂĔĈđĠēąđäăĂđĉäĘąĀĘĂĉĺƵĒǘĘþëčĒąčćăŪýéýĘćĠđĘĀđíĉćĖþĔƟĀđąēƵđĒȼĉčćĠĎíĠđĠƵđăƟĀđąēĉ
čáĒǘȼĒąąĉýēčĎĒĂąŪđĎēĉĒčĀäăĂđĉčĒćĘăĺăċïĉđĎĊÞãĂĔƣĎăĕąŪïäăĂđĉąƟđáïĒĎčđĘąĉþÿƟđąĊēčþïŪþđĉčđĘÿăĕĜĉĂïĘĉƵʅđąăëöđþēĠăĒĉôĠăĘëĉ
ãĂĔ˚ă˰đǘĉëąáĺĉĒĆĒĂçʁƟđĘɑĉçăĉĒĀĘĠăĕĂŪĂđćĀʅðþïĘĉäăđĂđĉĒĂïùʆĺïđɑđĂēĉãĒĄĘč˰ċĉēĘĉçăĒʆþĎĘĠĺôïƣĎĘĂĉöĂƟãĂĔĘĉđāïĉđĎĊÞ

āĂƟąđĀđĘȭ
ïþĖŪăǘĺčđĂđĊēĊđåĄåĂčĔƟĘĉȷĺïđɑđĂēĒĊĒćĘùû

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Issue by Claim Dept. Witness by Verified by local/Head office Approved by authorized

with seal FA/UM/BM/SGM/SAMD with seal officer with seal