Maturity-Survival Claim Form

Annex - II
CLAIM FORM FOR MATURITY/SURVIVAL BENEFIT OF PLI/RPLI POLICY

(Please fill in BLOCK letters)
Service Request No. :

(For Official only)
1 Policy Details :
i Policy Type: ii Policy No. :
iii Name of Insurant : iv Sum Assured :
Date of Acceptance :
v vi Premia Frequency (Monthly/Quarterly etc):
(dd/mm/yyyy)
Date of Survival Benefit Due : Date of Maturity :
vii (dd/mm/yyyyy) OR (dd/mm/yyyyy)
(AEA Policy)
viii Loan taken against policy : Yes No
Date of last Installment of Loan Repayment :

If yes, Loan Sanction Amount :
(dd/mm/yyyy)
2.
Outstanding Loan Amount :
Missing Credit Premium Details: …………………………………………………………………………

3.
(in case any premia paid is not included in the Intimation Letter)
4. Communication Address :
Address :
District : State :
PIN Code : Contact Phone Number :
Aadhar Number : e-Mail ID :

5. Name of Spouse (in case of Yugal Suraksha Policy):
6. Office Address of DDO (For Pay Recovery Policy only)
Name & Designation of DDO: Name of Organization:
Office Address: District & State :
PIN Code : Phone no & email id:
7. Account Details (if payment desired through NEFT/Credit)
Bank Account Details Post Office Saving Bank Account Details
Account Number: Account Number:
Account Type: Name of Account Holder

OR
Name of Account Holder: Post Office Name :
Name of Bank: CBS Post Office (Y/N):
Address or Branch Name: Pin code/SOL ID

IFSC code: First page of Pass Book Enclosed (Y/N)
Cancelled Cheque Enclosed (Y/N):
Documents Enclosed: Yes/No/ NA(Not Applicable)
1. Original Policy Bond or Letter of Indemnity
2. Self Attested copy of ID proof of the Insurant
3. Self Attested copy of address proof of the Insurant
4. Documents of Credit /Premium Receipt Book (D.O.C. if Pay policy or Premium Receipt Book if Cash Policy and all the paid
premium not updated on McCamish Software)
5. Loan Receipt Book (if outstanding loan amount as mentioned in Intimation letter and Loan Receipt book differs)
6. Cancelled Cheque of Insurant Bank Account for Bank Mandate or self attested copy of POSB passbook
7. Self-Attested Copy of ID proof of Messenger (if messenger appointed by Insurant for submission of Maturity claim form)
8. Self-Attested Copy of Address proof of Messenger (if messenger appointed by Insurant for submission of Maturity claim form)
9. Self-Attested medical certificate of insurant from Govt. Hospital/Govt. accredited hospital
Or
self-attested copy of passport clearly showing visa details and date of departure from India In case messenger is appointed
10. Any other document(s), pls specify ………………………………………………………………………………………………
Date : ______________
Appointment of Messenger
(Required only if Maturity/Survival claim form is being submitted through Messenger)
I hereby declare that I …………………………………………(insurant name), am unable to visit post office, being medically unfit
or outside India, for submission of Maturity/survival benefit claim form. I hereby appoint Shri/Smt./Ms.
…………………………………………. (name of messenger), whose signature is given below, as a messenger for submission of my
maturity/survival benefit claim form along with necessary documents.
Signature of Messenger ………………………………..

Name of Messenger ……………………………………
Signature/Thumbprint of Insurant
In case Insurant is illiterate, there should be two literate witnesses-
Witness Name & Address Signature

Witness 1
Witness 2
----------------------------------------------------------------------------------------------------------------------------------------------------------------------
For Official Use
Certified that I have checked all the documents enclosed and compared with the original documents produced by the
Insurant/messenger and verified the averments made in the Maturity claim form based on these documents and found no
discrepancies.
Date:- Signature of BPM/SPM/PM/ CPC in-Charge

Name :
Designation:
Office Stamp:
Acknowledgement Slip
(To be filled by BPM/SPM/Post Master/CPC in-charge and Handed Over to Insurant)
Maturity/Survival Benefit Claim Form for Policy No.___________________________with Service Request No.________________
received on …………………along with following documents:
Documents Enclosed: Yes/No/ NA(Not Applicable)
1. Original Policy Bond or Letter of Indemnity
2. Self Attested copy of ID proof of the Insurant
3. Self Attested copy of address proof of the Insurant
4. Document(s) of Credit or Premium Receipt Book
5. Loan Receipt Book
6. Cancelled Cheque of Insurant Bank Account for Bank Mandate or self attested copy of POSB passbook
7. Self-Attested Copy of ID proof of Messenger
8. Self-Attested Copy of Address proof of Messenger
9. Self-Attested medical certificate of insurant from Govt. Hospital/Govt accredited hospital

Or
self-attested copy of passport clearly showing visa details and date of departure from India
10. Any other document(s), pls specify ………………………………………………………………………………………………
Date:- Signature of BPM/SPM/PM/ CPC in-Charge

Name :
Designation:
Office Stamp:

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Annex - II

CLAIM FORM FOR MATURITY/SURVIVAL BENEFIT OF PLI/RPLI POLICY

Service Request No. :

i Policy Type: ii Policy No. :

iii Name of Insurant : iv Sum Assured :

viii Loan taken against policy : Yes No

Date of last Installment of Loan Repayment :

Missing Credit Premium Details: …………………………………………………………………………

PIN Code : Contact Phone Number :

Aadhar Number : e-Mail ID :

Name & Designation of DDO: Name of Organization:

Office Address: District & State :

PIN Code : Phone no & email id:

7. Account Details (if payment desired through NEFT/Credit)

Bank Account Details Post Office Saving Bank Account Details

Account Number: Account Number:

Account Type: Name of Account Holder

Name of Bank: CBS Post Office (Y/N):

Address or Branch Name: Pin code/SOL ID

Cancelled Cheque Enclosed (Y/N):

Documents Enclosed: Yes/No/ NA(Not Applicable)

1. Original Policy Bond or Letter of Indemnity

2. Self Attested copy of ID proof of the Insurant

3. Self Attested copy of address proof of the Insurant

premium not updated on McCamish Software)

9. Self-Attested medical certificate of insurant from Govt. Hospital/Govt. accredited hospital

10. Any other document(s), pls specify ………………………………………………………………………………………………

Signature of Messenger ………………………………..

Witness Name & Address Signature

Date:- Signature of BPM/SPM/PM/ CPC in-Charge

1. Original Policy Bond or Letter of Indemnity

2. Self Attested copy of ID proof of the Insurant

3. Self Attested copy of address proof of the Insurant

4. Document(s) of Credit or Premium Receipt Book

5. Loan Receipt Book

7. Self-Attested Copy of ID proof of Messenger

8. Self-Attested Copy of Address proof of Messenger

9. Self-Attested medical certificate of insurant from Govt. Hospital/Govt accredited hospital

10. Any other document(s), pls specify ………………………………………………………………………………………………

Date:- Signature of BPM/SPM/PM/ CPC in-Charge

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