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LIC
INTERNATIONAL
(~Jk.lt) aL.u.JI JU-<:.:,.,....ol.J1 u.=,_...
Corporate Office
1st Floor. Ali Al Wazzan Bldg .. Al -K haiifa Avenu e
P.O. Box 584, Manama, Kingdom of Bahrain
Tel. : +973 17210610. Fax: +973 17211577
E-mail : intcolic@batelco .com . bh
lifwJt\CUfGI\C e C01'P on1tio1t lJn!traa.HoM\) 8 .S ,Ci (c) Website: v.ww.lir.i nternc1\i on al.corn
I C R . No .72 C.R. No.: 21606

DISCHARGE FORM FOR SURVIVAL BENEFIT

UNDER Professional Education CWith Guaranteed Addition)
Date: 02·06·2020
S.A :USDlOOOO Plan&Term:219/19Years

Re:Policy No. - 400809700 on the life of Mr ABDUL HABEEB MAHABOOB BASHA (LA)

I, the Pro;Poser I Life Assured do hereby acknowledge receipt from the Life Insurance Corporation
(Internat1?nal) B S C (C) the sum of USD ~00~.0 in full satisfaction of all my claims and demands in respect of
the followmg payment under the above policy m terms of the policy contract for which the policy is hereby
delivered for Endorsement.
L 20% of 8umAssured which fell due on 10-08-2020:Uso 2000.0

jLESS
- - - - - - - - - -- - - -- - - - - --. ----- - - - -- -
iUn13aid Prnmiurn 0.0
r-- -- - - -- -- - -- - - -- -- -- - r---·- ·-· - - -
!Interest on Unpaid Premium 0.0
!other Deductions 0.0
iTntal Deduc.!ians Q.Q
jNet Amount Payable 2000.0

I hereby declare that, I have not assigned the above Life Insurance (Int'l) BS C (C) policy to any one nor shall I
serve on the company any notice or assignment or reassignment before payment of the Survivai Benefit.

J2.!!..G.~L. on the ../.~-~day of.-;T,1/.t!JF.. 2~2.0. /\1~

Dated at
.-,\~~ .
········ ·· ················ ··············-
Signature of the Life Assured

Tel No.: 0?0.- bib8 937

Witness
Signature:
Name :
Address:

USD($) BHD L] KWD D AED D SR D OMR D QTR D ri~'R l.S2J

For Other Currencies Please S ec·
Mode of Payment

(*)CHEQUE (**)TELEX TRANSFER DEMAND

DRAFT

l*BHD,KWD,AED,QR &OMR only

I ** Please complete and submit Annexure I

Note: This is an advance receipt and is valid only after issuing Cheque/DD by LIC Unt'l) .

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