ll[E]

""""' ~ ~ ~
LlfE INiUIWIC( CORPORATION Of" lhDIA
LIFE INSURANCE CORPORATION OF INDIA
(Established by the Life Insurance Corporation Act 1956}

CHE NNAI DIVISION - 1 INT No.

Discharge of Policy No. dt.

Life of maturing due on

I/We

the Lite assured/assignee(s) Trustee

do hereby
ackn ow ledge receipt from the Lite Insurance Corporation of India of the sum of

Rupees

the gross amount of claim, in full satisfaction of all my/our claims demands on respect of the

following paym ents under the Policy in terms of the policy contract.

I/We hereby declare that I/We have not served on any Office of the Life lnsurijnce Corporation of India any notice of assignmen t or
reassignment in respect of the above POLICY/IES except those, if any already registered by the Life Insu rance Corporation of India or the
Insurer wh o issu ed th e above POLICY/IES nor shall I/We serve on any offi ce of the said Corporation any notice of assignment or
reassignment before payment of the survival ben efit/ maturity claim under the policy due on . . ................. ................. .

I/We have not Dealt with Policy in any other way.

Policy is hereby delivered to th e sai d co rporation fo r cancellati on/endorsement

Dated at th is day of 201

Signed Shri/Smt. .. ............. .. ............ .. ... ........ ............................. .

in the presence of .... .

Signature of witness ...........

Particulars of witness ... .. .. .. .... . Revenue

Stamp of
Full Name ... ............. .... ... ........... ........ .... .......................................... . Re.1

Designation ........ ............................................ ... .. .......... ............ .... .

Address .................... .... ............. .................... ....... .... .... ............... .

(Signature/s of the Claimant/s
1) Payment will be made by an Account payee n t q •table Cheque. If Payment is desired by M.O. or a demand draft. It
can be made at the claimants cost and at .,, s 'her r•-k and responsibility on hi~/her signing to the following n0te nf
request.

I/We hereby request the Corporal on to pay t"e a'oresaid amount by 1-J O Dem;:,nd Om~ on •t1r
Bank.

at my iour risk and respo~s,b ty r .gree to tre M.O comrr ss,on 1Bank cnarges being deoue,1ed lrurn ,ne
claim amount.

(Signature of the claimants)

2) This discharge must be signed by thE ~ 1fe Assured and witnessed by a credible person who is conversant with
the language of tr s fo•m and Kriow~ t'1e I !c 2 sured

3) If more than one pe•son 'lave c; qnE''"' • d ,ch ·ge fc•m , tre riames of all the persons should :,e st8terl

4) Illiterate claimants must affix the, triumb ,mpfessio'l which should be attested by a magistrate or Special Executive
Magistrate or a Gazetted Office• O' d B oc K Development Officer or a Class 1 Officer of the L.I.C. or a Developml ..
Office of the L.I.C With at least five ycarc; serv, e ~i, .. attesting witness must make the following declaration UMPf
th. s signature .

"Shri/Smt. ....... .

Son/Daughter of Shn

......... . . . .. ........ .. ........... ......................... ..... and

Wife/Widow of Shri .... .. . . .. . ..

... ....... ...... . ............ .... .. .. . .. .... . . . ... . .... .. .... .. .... . .. ....... .... ....... .. .... .... .................. has affixed his/her thumb
Impression in my presence after understarding the contents r ere or

5) Since our records do not show that the fina, premium due or
under the policy has been pad we have proceeded on the assumption that it remains unpaid and have calculat8d tl1e
claim amount on that basis if however the said premium has already been paid the amount thereof will be refunded
along with the claim amount. T enal . us to trac~ t!-ie payment of premium 1f al ready made, please inform us the nanw
of the office or Bank where 1t v% . :land t'1e da:e and number on the deposit receipt issued thereof.

6) Signature/s of the cla1manUs otrier than ~ 1e Ass "erl should be attested by one of the officials as mentioned in the Note
No (4).
If the with·.-, written discrarge ,s Si£ ~~-Joy more than one person and payment is des,rea to he made'·>
only one of them , than the following Note of Authority must be completed and signed by all of them before a Magistrat ,·
or a Special Executive magistrate or a Gazetted Officer, or a Block Development Officer, or a Class 1 U ficer of lh8
Corporation, or a Development Officer of the Co•poration with at least five years service. provided he is fully satisfied
about the identity of the executarts.
Place: Date:

I/We hereby authorised and request the L I C cf ndia to pay the within mentioned amount of Rs . . .. .. .......................... ,.. .

Signed by the parties w tr ri rrient oned i"' the presence of

Witness
Signature ... ...... ... .. .

Full Name ......... .. .

Designation Signature m full (Officia1 Seal

of the Authority)
Address .. ... .

I Certify that the contents o' this Note of Aut 11ority were explairied by me to Shri/Smt.. .. .. .... .. .. . ... .. ... .. ....... ... .... .
... .................... .. . .. .. . . ... ....ar,d re>lsre/they have agreed to payment being made of Shri/ Smt......... ... .. .. . .. .. .... ..
. the authorised µc:111y.