INSURANCE FOR KHADI KARIGAR
"JANASHREE BIMA YOJNA"
CLAIM FORM
LIFE INSURANCE CORPORATION OF INDIA
CENTRAL OFFICE, MUMBAI

GROUP INSURANCE SCHEME under JANASHREE BIMA YOJNA

M.P. NO. GI/JBY/………………….

CLAIM FORM

PART – A (To be completed by the beneficiary)

1. Name and address of the deceased member    
2. Name and address of Nodal Agency    
3. Membership No.    
4. Date of entry into the Scheme    
5. Name of Father/Husband    
6. a) Date of death :______________ b) Age at death :______________
7. a) Place of death   :______________ b) Cause of death   :______________
8. Name of Nominee    
9. Full address of nominee    
10. Relationship with Member    
11. Name and address of Bank and S.B. A/c. No.    

I hereby declare that the answers to all the above questions are true in every respect.

(Signature of beneficiary)

Witness : (Signature)

Name : ________________________

Address : ________________________

PART – B (To be completed by the Nodal Agency)


Certified that the replies to the above questions are correct in every respect. Nominee named above is registered in the Register of Nominations at Serial No. __________.

seal

(Signature of Authorized Signatory of
the Nodal Agency / Master Policy holder)

PART – C


DISCHARGE RECEIPT

We_________________________________________________________ hereby acknowledge receipt from Life Insurance Corporation of India a sum of Rs. __________ (Rupees ___________________________________) in full and final satisfaction and discharge of all our claims under the above master policy on the life of member ____________________________.

Dated at _________________ this ______________ day of __________________ 20___________.

Revenue Stamp
SEAL
(Signature of Authorized Official of the
Nodal Agency / Master Policy holder)

PART – D


Please send the claim amount by cheque to the credit of Savings Bank Account No._______________ held by the beneficiary with ______________________________.

(Name and address of the Bank)

SEAL
(Signature of Authorized Official of the
Nodal Agency / Master Policy Holder)