Third Party Declaration For Partnership Firm

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Third Party Declaration Partnership Firm

Application/Policy No.- ___________________


Payer/Partnership Firm Name :____________________________________________________________
Address: ________________________________________________________________________________
________________________________________________________________________________________
We are the partners of the above mentioned Partnership Firm and we hereby confirm that we
do not
have any objection in firm paying the premium for our partner
Mr./Ms./Mrs.__________________________,the proposer/Life Insured for the above mentioned
application /policy number.
Partnership firm shall be paying on behalf of Mr./Ms./Mrs.______________________________due to
reason ___________________________________________. Further, I/we understand that the
proposer & Insured of this policy shall be not be eligible for Income Tax benefit u/s 80D
under this policy.
Please find the details of the payment below:
Cheque /demand draft no._________________ dated _____________________drawn on bank for an
amount of Rs. _____________ (Rupees _________________________________________ only) for
Health Insurance policy/application as mentioned above.
I/We hereby declare that the information given by me/us above is true & correct. Request
you to accept the remittance

Date : dd/mm/yyyy

______________

______________ _________________

Place:

(Name & Signature of partner/s )

Declaration By Proposer/Insured
I ______________________hereby confirm that (Firm Name)________________________________
Is paying on my behalf for above application no./policy no. I further confirm that all
information given above is true & correct
Date : dd/mm/yyyy

______________

Place:
proposer/insured)

(Signature of

Version No. 1 Date 7th Oct 2014

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