Scribd Logo
Upload

Welcome to Scribd!

  • 32 views

    GSLI

    Uploaded by

    Anant Rao
    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.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    GSLI

    Uploaded by

    Anant Rao
    32 views2 pages
    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.

    Original Description:

    LIC GSLI Claim form

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    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.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    32 views2 pages

    GSLI

    Uploaded by

    Anant Rao
    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.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    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: ----''-- __

    You might also like