“ereefra sergféten srmriars serafra afrera efter frre JA pees wmratera — | PUNE DIVISIONAL OFFICE -1 voce ge tg fens eh, OF POUCY NO. Onthetoo! eros gfe Dato 8 / roc teeccrn ein vex ore FAR / rari fee as rc soy ate Fe Fra tore sey orcaren my pgorchan oY agen aA, fern ae ae whoa aon Fy rer TT ena / feel S20 03 cA haved erm apn Pathe a A / ent si Fe, aka ea / erty eu / Prastan Berar apr i gl avn fe Pech inka wh stort aren aaron Bee agen dn / soar wr Fa aan aon 8 rrcis a Fm A Wa hereby declare that YWa hava not served on ary Ortce of tho Le Insurance Corporation of india any notice ot assignment oF reassingnment in respect ofthe above POLIGY / POLICIES excep! thosn # any aveady registrerad by {he Lifa insurance Corporation of india ofthe insurer who Issued the above POLICY | POLICIES nex shall /We werve onany effce of the said Corporation, any notice or assignment ar reassingnine nl belore paymant of tha Loan Valuo / SurerderValue or survival benef duaon Nave not deat with potcy im any other way, im organ, wre ta a Be 2 ree rfeaah ih Fe oem tm Brae with eg Oh aed 9A ep, hr ane ea en era fat Ot amen phen Rexana / feartta ng arene Rerent ton bg sfieast 4 area wen: 2 Ania A oh wr ea Reais ait 20. 18 ooh re eatin Wwe: ‘do hereby acknowledge receipt from the Life neurance Corporation of india ofthe sumofRupees: tng tne Surrenctor Valu inctucing Cash ‘Value of Bonus and premiums rehundable on account of occupational extra and/or DABYEPDS extra ol the above mentioned policy, which is herewith delivered up lo the sald Corporation to be cancelled. in winess wherect these [presents are subscribed by me/us. a one, dayot 20 (Name of the place) (Date) (Month) sare pa (ata 7 HET-AHha) SURRENDER VALUE (Inclusive of Cash Value of Bonus) “arava sition 2g sfitaa ave Promium retundable on secount ot accupatianal extra. Fe. ‘Bet gden fers / Frei end are Revenant sro ech FORM OF RECEIPT FOR THE SURRENDER VALUE Premium refundable on account of D.A.B./E. PDB exra = wert / Less ¢ inOeerPay | FR Loan {BIA Intarest hes mM APL. we ‘BA mnE Other Charges (ZAM to be Specified) ¥. a 1A0/ BM & ‘Total Amount Payable : * Sef art ar HINDI- KNOWING WITNESS : 7 ‘Wr Signature 1a, Fovenoo ‘a2 GI AT a Ge Full Name & Address ot the waness owe fore ‘Stamp When wal. $000/- arort a fe Ris, 5000- Tan Sigrakure ain ga wees fs sd emat eee Gross amount of Surender Valuo olete where nat appticable (roa: Frere anf ot one 3 an Bara corn anf rer aaa eres ater tarred wre A aes ea fet Bin andar Zee, wae frame sitter aren candies afar’ am A ar fea | aba eras a faq eer ag sf (RA tart afacd & em eaifita fem wer arf, 1 poeta acta OA arfaeed evetirert, fade rte worfirert, wae fee fired seen aaeiaa sifireTf #1 fer ire ger zn aed | Nott : literate porsons must atfix ther thumb marks which should be identified bry the attesting Magistrate uncer the seal of his office by a Sp. Ex. Magrstrato, Block Development Otficer or a Gazelted officer. Signature in Regional Languages must ba attested by respaclable English-knawing persons, The withess atiesting such Signature and the Magara, Ex Mopir=te Black Devobomért Orter ora Gaze oficeratening uri marke shoul ot Deskerdee 7vO7 N= tao