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GSLI

The form requests information such as the name of the insured member, employee ID number, salary grade, insurance coverage amount, date of birth, entry into the scheme, monthly contributions, exit from the scheme, beneficiary, and proof of death. Head of the department must confirm the details and that all premiums were paid. The beneficiary must receive the approved benefits upon signing a discharge receipt.

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Anant Rao
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89 views2 pages

GSLI

The form requests information such as the name of the insured member, employee ID number, salary grade, insurance coverage amount, date of birth, entry into the scheme, monthly contributions, exit from the scheme, beneficiary, and proof of death. Head of the department must confirm the details and that all premiums were paid. The beneficiary must receive the approved benefits upon signing a discharge receipt.

Uploaded by

Anant Rao
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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LIFE INSURANCE CORPORATION OF INDIA

"DIVISION OFFICE NEW DELHI"


CLAIM FORM
CLAIMING BENEFITS PAYABLEUNDER GROUP SAVING LINKED INSURANCE SCHEME
MASTER POLICY No. GSLI / 46864 (NDMC)
(To be completed by the Grantees)

1. Name of Institution NDMC, PALIKAKENDRA,NEW DELHI-HOO01

2. Master PolicyNo. GSLI/46864

3. Name of the Insured Member :

4. Employees/assurance No./Sr. No. in the list :

5. Category/Salary Grade :

6. Amountoflnsurance Cover :

- ~
..- ..
7. Date of Birth :

8. Date of Entry in the Scheme :

9. Amount of Monthly Contribution recovered from the Insured :


member

10 If there has been a change in the monthly contribution during :


the member ship, indicate dates of change and the revised
contribution

H Due date of payment of first contribution (Indicate day, month :


& year)

12 Date of exit from the Scheme :

13 Due date for the payment of last contribution (Indicate day, :


month & Year)

14 The date on which the last contribution was paid to the


corporation

15 Mode of Exit (Death/Retirement/Resignation, Termination of :


Service)

16 cause of Death (In caseof exit by death)

17 Was the member absent on ground of ill health on the date of


"

entry in to the Scheme(if so, give detail of leave)

18 Name of beneficiary andrelationship to the member (In case of :


death)

19 Nature of proof of death (Plea~e Enclose Original Death :


Certificate)

:
20
give details
.. -
Whether any premium remains unpaid during membership, if so,

We declare that the above particulars are true and correct and the above member was an insured
member covered under the scheme on the date of his exit and that all premiums have been paid to the
corporation on his behalf.

Head of Department/Office'(wlth Stamp)


We confirm that beneficiary mention above is the person appointed by the member'

receive the benefit under the Scheme.

Dated at this day of

________ 20 _

Signature of Head of Department!


Authorized Signatory
WITNESS:

Signature: _

Name: --'- _

Address: _

Discharge Receipt

Received a sum of Rs.


-------------------------
(Rs. _

from the Life Insurance Corporation of India in full and final Settlement of all our claims and demands

in respect of Shri/Smt. Assurance No.

__________ under Master Policy No. who expired / Left

Service / retired on _

Dated at this day of

_________ 20__

Revenue
stamp
Rs. 11-' .

Signature of the authorized signatory

Name:
-------------
Designation: _

(OFFICE STAMP)

WITNESS:

Signature: _

Name: ---'- _

-Designatlon: _

Address: ----''-- __

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