FORM NO.
3801
Divisional Office _____________ Branch Office _________________
DISCHARGE FOR DEATH CLAIM UNDER POLICY NO. _____________
Dated _____________ On the life of Shri/Smt _______________________________________
I/We the nominee(s)/assignee(s)/legal representatives of the above
named life assured by virtue of the nomination/assignment/legal evidence of title dated granted to
me/us by the do hereby acknowledge receipt from the Life Insurance Corporation of India, of the
sum of Rupees(in words) including the amount of Bonus, in full and
final satisfaction and discharge of all my/our claims and including the amount of Bonus, in full and final
satisfaction and discharge of all my/our claims and demands under the above mentioned Policy on the life
of the above mentioned person, who died on and which policy is hereby delivered upto the said
Corporation to be cancelled :
Sum Assured/Paid-up Value Rs
Bonus Allotted/ Loyalty Additions Rs
Interm Bonus Rs
Final Additional Bonus Rs
Difference of premium on account of
overstatement of age Rs
Refund of extra premium for Sex, DAB,
EPDB and Occupation Rs
Gross Claim Amount Rs
Less
Unpaid instalments of premium due in the
Policy year of death Rs
Late fee thereon Rs
A.N.F Debt Rs
Loan Rs
Interest on Loan Rs
Amount recoverable on account of
Understatement of age Rs Rs
Others Rs Rs
Total Deductions Rs Rs
NET CLAIM AMOUNT Rs _______________
Dated at this day of
1 Re.
Revenue
Stamp
Signed By Shri /Smt
in the presence of *
Signature of witness Signature of claimant/s
Full Name Father’s Name
Designation Husbands Name
Address Address
Notes :
(1) Payment will be made by a crossed and order cheque, if payment is desired by M.O (Net upto Rs.
1000/- only ) or a Demand Draft, it can be made at the claimant’s cost and at his/her risk and
responsibility on his/her signing the following note of request.
I/We hereby request the Corporation to pay the aforesaid amount by M.O /Demand Draft
on the Bank, at my/our own risk and responsibility.
I/We further agree to the M.O. Commission/Bank Charges being deducted from the claim amount
.
(Signature of Claimant/s)
(2) This form must be completed before (1) an advocate, (2) an Agent of the Corporation (who is a
member of an Agents club at the level of Divisional Manager’s club or above), (3) a Bank Manager,
(4) a Block Development Officer, (5) a Commissioner of Oaths, (6) a Doctor, (7) a Gazetted
Officer, (8) a Head Master of a High School, (9) a Head Post Master or Departmental Sub-Post
Master but not a Branch Post Master, (10) a Magistrate, (11) An Officer or Development Officer of
atleast 3 years standing (12) A confirmed Development Officer recruited from the Agents, who
were DM or BM Club Members before joining (13) A Development Officer recruited from agents
who were ZM or Chairman’s club members before joining (14) President of a Village Panchayat or
Local Body.
(3) If more than one person have signed the Discharge Form, the names of all the persons should be
stated.
(4) A female when signing, must add her father’s as well as her husband’s name after her own,
describing herself as a daughter of Shri and wife/widow of shri
(5) “In case the claimant affixes thumb impression or if this form is signed by more than one person and
payment is desired to be made to only one of them as per the following Note of Authority completed
and by all of them, the thumb impression or the signatures on the letter of authority must be attested
by an Agent of the Corporation (who is a member of the club at the level of Divisional Manager’s
club and above), a Block Development Officer, a Magistrate, or an Officer or Development Officer
(with at least 3 years’ service as Development Officer) of LIC or a Bank Manager of Branch of State
Bank of India or of one of the nationalized banks (provided the attesting Branch Manager signs after
affixing an official rubber stamp giving his name and designation as also the name and address of
the Bank where he is working) or the Principal/Head Master of a local High School or Higher
Secondary School run by Government. Where thumb marks are affixed, the attesting official must
make the following signature under his signature :
“Shri/Smt son/daughter of Shri and wife/
widow of Shri has affixed his/her thumb marks in my presence after
understanding the contents thereof.”
Place Date
We hereby authorize and request the Life Insurance Corporation of India to pay the within
mentioned amount of Rs. to Shri/Smt
Signed by the parties within mentioned in the (1)
presence of :-
(2)
Witness
Signature (3)
(Signature in Full)
Full Name :
Designation :
Address :
I certify that the contents of this Note of Authority were explained by me to
Shri/Smt and he/she/they have agreed to payment being made
to Shri/Smt the authorised party.
(Signature of Witness)
