[SHRIRAM LIFE INSURANCE COMNPANY LRATED 7 SHRIRAM Divisional office: Ronis ort, Branch Office CLAIM FORM “c” YOUR PARTNER FOR PROSPERITY aE ec smsncun Sanka ox se ar. CERTIFICATE OF IDENTITY AND BURIAL OR CREMATION SAAB R ATT AAPA TATE (To be completed and signed by a person of known character and respectabilty acquainted with but not retated to the deceased neither to the claimant, and who saw the dead body or who has present atthe burial or cremation of the body of the deceased.) OSA ENN TTR ATA aH REI ERT 1 MS AT HT AG I AAS TS TS, STRAT TSR ARTA AT TTT (in connection with claim under policy No an Sean Baa aon (inser ful name ofthe deceased) casera fn the lite of | hereby make the folowing statement area PP Pe 1. Name of deceased in ful Ie TT ‘aye Tae TT TE YS See aN aT Me TATA (8) Was he related to you? If so, How?, 4. (A) Date and time of Desth?, 2. Name of the deceased's father in fu 3. (A) How long was the deceased known to you? He ANN aT HE TATE, FEST I ofa IT (8) Cause of Death gE FE (©) Place of Death TER (0) Duration of ness. NOTE TST ‘STR Bee CH HOM (ES aT Tae CAPES aT SPA SF aT, CRIS AT TRAE SHOT FRE? (C) Was he stout, thin or medium in build? (0) Approximate age at death 5. (A) Describe any distinctive mark or physical Peculirty of deceaged, (8) Was he tall, short Fre i igh $$ $a fafa ree anata sre ae Peta? AQ IS Se TT ga Be omer tea Reed (Sra He Cm, A 7. (A) When did you last see him alive? (8) Did you see the body after death? dye: GE ae aT Cae ORT 7 6. Deceased’s occupation immediately prior to death with address of the employer, if any ar cr a OT SHG CONTRA? One(©) Was the body buried or cremated? C1 buries Ocrematea Ble mf cso aatied aT ee eT REN? cock Oem Oem OORHOOOO (0) Time and date of burial or cremation? a Sas ST PIATRA AAR AR OT? (E) Name and address of place of burial or cremation? TT TTATRA STATA ESTA? () Were you present at the time of burl or cremation ofthe body’? yes ()no a ee SH APPS SAPS Oe O 8, Are you aware that the deceased's ie was insured with the Shrram Lie Insurance company Lis. []ves []No Sn RroTECTapER TaRMS Rare RSIS Sea eaT eA | certy thatthe Body which was buried or cremated was that of the person named above and do hereby declare that the foreging statements ae true and eorect othe best of my knowledge and bet BAR ar AR xR HTT TT FATA TMA ER ROTI STRICT ARC TE SOM AMAA ox Remo ASH OTT Signature of Declarant eR EET Occupation orn Name. 7 Address, {eer Completed and deciared before me this oy of goog SRA TR FAT PT ATT fcr ae ae Counter Signature Adress fem ‘Sere Name =m Designation 5 (Please see Note below) Gqureaiisastacey NOTE: 58a This statement must be countersigned by (1) An Advocate, (2) Any authorized official of Shriram Lite Insurance Company Ltd, (3) A Bank Manager, (4) A Block Development Orfcer, (5) A Commissioner of Oaths, (6) A doctor, (7) A Gazetted Orfcer, (8) A Headmaster ofa High School, (9) A Head Post Master ofor Departmental Sub-post Master (but nota Branch Post Master), (10) President of Vilage Panchayat of Local Body. 22 Aegfee Roeee same a ATT UE (1) SFT ATRTETHS, (2) Sam ote Tao Fe PER aFET aE Heh, (3) J50H URE RTO, (4) 268 ae Ea BAAS, (5) seam FAA we ON (6) SFE SHR, (7) 2FaF OTAGS oon, (8) 2a ‘Be Rema arom Pose, (9) ee PE Pa aT RoR Tee APR (Se CH TAR TIPE APE AR) (10) TAN ST aT ARIES TST CERTIFIED THAT the contents ofthis Certificate were explained tothe dectarant inthe Regional Language and gaps fled on his cctation. afar tie aa rere cearmcere SATA STANT RAT MAR 2 28 TATA ATA eT PAT TET Signature of witness sola asa Nam a Address fee