anda orgie verse Heat ater fre LUFE INSURANCE CORPORATION OF INDIA Jaffee y Sete 1/ MUMBAIDIVISIONS age ar afar DISCHARGE OF - (1) arerfeifar fan ciferettemretter ata Raesen / arer-aireerftra dian Uifereht 25 sictola arene PaeseT * CASH OPTION UNDER C.D.A. POLICY (2) Refrenar citer ameter waren caer / Per cremay Were & siawia oPeaaa areas * MATURITY PROCEEDS UNDER TRIPLE BENEFIT POLICY. (3) srtfara wedhdic fereh, ten weet atoran, dren anhr eizaro cifersh sath sraRare entire eHereA rear SHAR ere, ster gel |r da / se te seen Sth TH. TASTE 30 Tee Pere eer, a fereh are cen sili Ga gh er ee A ere ee HITS. LA ‘at 30 wfcterat feterarore ee | * ANTICIPATED INSTALMENT UNDER ANTICIPATED ENDOWMENT POLICY, MONEY BACK POLICY CASH & COVER POLICY & ANTICIPATED WHOLE LIFE POLICY. JEEVAN SURABHI, JEEVAN SANCHAY, JEEVAN SNEHA, SURVIVAL BENEFIT OF 30% THE GIS AMOUNT UNDER JEEVAN AKSHAY. (4) are arte certiontter 0 eae ecco eae aren Teen Rrr ere & aicrofe 50 wafer serena at erat Return of 50% Premiums under Children’s Anticipated Policy. ae SEN oa aac e agg EE wreeres / afer Heated era or HAG TEE a TE enced uel’. grovel aire gree ee eerand/ yoloaterel Sie mene. A wecraes | Sie, gach eT 2 enka UA ora ecigere, Frets a eh reer gelra ea bg ae mae, Frito erent aera aca wel ee EE Tear eaiee see Brae ra ears ee & | \ the Proposer/ Life Assured do hereby acknowledge receipt from the Life Insurance Corporation of India the sum of Fupees_______in full satisfaction ofall my claims and demands in respect ofthe following payment under the above Policy in terms of the Policy contract, for which the Policy is hereby delivered for Cancellation/Endorsement. (1) ahr tea ere art he ere ae ahem. ‘sachet re-read ra savin tales ada apreratgiane | Cash Option which fell due for payment on under the above Children’s Deferred Assurance Policy. (2) were onmattea RBA enor cee each Rater aertageer aa ghee wear Per ere eh soko oer ae ‘Sum Assured which fell due for payment on the date of maturity, viz_________ under the above Guaranteed Triple Benefit Policy. (0) abies wae eh er ce e/a ear eh ee ches eR / pee ce ee Frere er GAA ‘sense eee ahaa ta eres shewta ates rr ig at tt Roe) erate ier aore cient STUY UreTA ean aR gts ere sieia oh.amer.va. tesa at 30 wiererat Anticipated instalment which fell due for eee ‘on under the above Anticipated Endowment Assurance Policy / Money Back Policy / Cash & Cover Policy /Anticipated whole life Policy/Jeevan Surabhi/ Jeevan Sanchay / Jeevan Sneha / Survival Benefits of 30% of the GIS amount under Jeevan Akshay. (PT.O.)adler aret artfaia ciferet aah Reiter Reateoraeia arctan eccereen (Sear eA Stee) 50 Tees ETAT LAT. sort eer seen were rz 0 frre saree aca rear eat wegane Frere area reenret Fetes Ratskemaatg Rah, sana A/set rer emai aifferera-aoaer srreren eae es Return of 50% of Premiums excluding extra Premiums, paid till the Deferred Date, which fell due for payment on under the above Children’s Anticipated Policy. 2a ait/2a aie Amount Payable Rs. wafer Less aeae etd / sea wife Unpaid Premium B. Rs. srearadicr ears / HifseaT Gz =e Intereston Premium — B. Utetatradiee se Policy Loan Rs. cearedte ars | FETT STA Interest thereon B. Rs. sree / searcher Other deductions @. Rs. faa tazaen/ gata Net amount payable &.Rs.. Sampara ater (@aaanpadaez) * Strike Out which are not applicable. Ash rare wet aozeh oA ate rete coer er re atch ey ee zen rein raises’ ra a rads’ aie see zg ar Geer ra eva are ore ets rend erehceree Ay ame TCA, aad a, are arecioen cfertasier Berane fret Por an art 2oensne merase rend crakear sarge Roa yaciageent git aa area aT. “Afr erga ee azar seer 8 a ch Te eee ie lad sa fh Bors PA aera a roar ax gastro ah aan aE Ae, Pra Tey, a a, Heat an fort srr sacha hy aa a oT apeaare daresefer op &, ate a a aif er siete ales ————__— aa fran een of2weaen eer sapere fers cere aver ern gash a8 hg ar gpT/2a | We hereby declare that I/We have not served on any Office of the Life Insurance Corporation of India any notice of assignment or reassingnment in respect of the above POLICY/IES except those, if any, already registered by the Life Insurance Corporation of India or the Insurer who issued the above POLICY/IES nor shalll I/We serve on any. ‘office of the said Corporation any notice of assignment or reassignment before payment of the survival benefit/Maturity claim under the policy due on Hanae Gece area Goer eres aT a, ‘Hao eter an Res area wa acetor al rer’ | We have not dealt with policy in any other way. Aeasro/Reaifsa eer Dated at Raiethis __afar/are day of teiied by Siro etme creme Cee TORT in the presence of ‘erchiare eanardt / Biehl Bea / Signature : WY pfara/ggrarat/ Full Name RN | %/8@/Designation & | umn/san/ Address: s Signature in full / short in English / in Vernacular Present address on which cheque is to be sent ‘year / Rami / Note: (1) Gees s-eecirestia sneren aad Bena (agratwcsren race) eet onset. wloreent doar aris ere Roar Het-sHisea een en cee re sarees sain rarer sta Sere RA ors Safer ers Tanaka es SMe |. aH. sHaRe ao Be argo FS refer ae reer em Sree Racer RRS HME / Hel site sre Ta cH OTST. ee‘gpretel Porat &s davai Tented aifferdter tes rer oer owraor | area veh aes Bais soe eM ranger grat Boar aa ‘oe on ato aE saree Fara TENS B Brea we @, Fes appre aris gre er eroneer arer TA Tees/ Te a ST ‘wrararerh} ue Rasen wire cen uifereh erat B dep wore are fra wre at oft ag /a TET e | Payment will be made by Not negotiable - Account Payee Cheque on the Corporation's Bankers Payment by Demand Draft on any Bank or M.O. can be made only if the payee/s give/s a consent letter on the following lines. that the payment by Demand Draft or M.O. be made to him/her them at his/her/their risk and responsibility and ‘also agree/s to the bank/money made to him/herithem at his/her/their risk and responsibility and also agree/ to the bank/money order charges being deducted from the Policy moneys. arr/ ZT / Place Rai Date, Ayia ore sean setae Ri eve 8 wea er cae Ras at, HET a Soa ge sma oH rahe rer Ae ae arc Bt ese / a, see Here ends aT RTT. sr ere oe ea a rr & sehr en ae secre er es we AY a a rahe ea a aig meer emcee | aifeat ya Ue car 8 des waa re a Ta aH BEATE | MWe hereby request the Life Insurance Corporation of India to make payment of the aforesaid amount by a demand Draft/M.0. on the the. Bank at my/our risk and. responsibility. /We further agree to the Bank Charges / M.O. charges being deducted from the Policy moneys. ) @ faanenzes/artere iat eaerhh / diene / ears wea Signature/s of the Assured/claimants/s (2) erg cra er ich erent DA RS sa gre oT sh Pi are Shes AA seemed meio FATS. ag Reg hese Bre et ree ta ere eh ea acer eet eer eh a ease te afta, ae as Sere a rae | This discharge must be signed by the proposer/Life Assured and witnessed in English by any English Knowing person provided he knows the Life Assured. (@) sete doce eerie efter fon rari Pear ARS. rey nr oa ora rea Ht Tat TH signe sraea a oT BA | Signature in Indian languages must have the English transactions written beneath. (4) aR aaa alread en seach area wae sere encanto CaN a see ARS, alse wake fete sre ae Rb cece ior ears ane, oe Reo ait, zoe afters, saree, Pat axerkecaer ten Rn Rvaet a et Sa gre Ree reo re err sen ae igh aa oat chat a Rote ween vee gen tare BER re nT Fry eer eer stron, wee des aes Ben Pret abit ver era (re ecient aecore Ror =Te eae ae af er eee sa A a ah SRT kata nf er eelFaoer e SHEA HT eae seh HS) bar eats ama even er aoTea arc TH renter eer pen mre / pea mecnt ae ARTS Ea eT MT HTN A TART, freare eel ard abs ar erator aR ree wera ira esa ae ise ders aera eae TSS sou aero aera, wie Ree ited (A. st.) aero aia, avs ara aig ee ere for ret or Ser gg Ben ere ors arene ch aren a Sega ver rer dh rg ate. aL a reese ee ae ie oh Ra ere eninge eer de (wer Rs a ere es ect eect vhez Bre sean ar, en as ear, wera ener & TE a Gea TAT wee’) ah wes RS, TTA rns pee eM AN ese eT EA veo eve 8 eins EAT ST wi feats thao ana secTare & Bret wea aT | aIlliterate person who affix their thumb impression must have it identified by & attested by an agent of the Corporation who is member of the club at the level of Divisional Manager's club and above, a Block Development Officer, a Gazetted Officer, Magistrate or an Officer or Development Officer with atleast 3 years standing or a confirmed Development Officer recruited from the agents who were D.M./B.M. club members before joining or a Bank Manger of the branches of STATE BANK OF INDIA or of one of the nationalised Banks. (Provided the attesting Bank Manager signs after affixing an official rubber stamp giving his name and designation as also the name and address of the bank where he is working) or the Principal / Head Master of a local High School or higher secondary school run by the Government. The attesting official must make the following declaration under his signature. aed. a. Bie wh err eae sree agen Soe aT TIE TERT IT. ay at agen] eh es en ear rere eae eee are waial Beare PoeT | Shim. Slo- Dio Wife offWidow of Shri has affixed his/her thumb marks in my presence after understanding the contents thereof, Maeaiesa BT sires STAY ‘oratcrerd at ‘mracieset siftresrd & wera wre a Bee Signature of the attesting official seal of the Office Ua. 5180 (87.27. geen: pr mererad Gioe Rare seeraeurer Goch once wearer Ug ee OTE. F. No. NaN fem: german a aga raat faith re @ tor ar oTUIT | Pr GeoU CaO Note _: Incase of dispute in respectot interpretation ot terms the Engsh version shall stand vali. ads