LIFE INSURANCE CORPORATION OF INDIA CLAIM FORM'A'
(To be completed by the Master Policy Holder for claiming benefit under the Group Saving Linked Insurance Scheme on Retirement or withdrawal of a Member)
1.Name of the Master Policy Holder____________________________
2.Master Policy Number______________________________________
3.Date of commencement____________________________________
4.Details of the member_____________________________________
| Name | Employee No./Serial No. | Category | Date of joining the scheme | Initial monthly contribution | Date of change/sin category |
| 1. | 2. | 3. | 4. | 5. | 6. |
| Amount of last monthly contribution | Date of exit | Due Date of last contribution | Date of payment of last contribution | Any contribution Date/Amount |
| 7. | 8. | 9. | 10. | 11. |
Signature of Master Policy Holder
LIFE INSURANCE CORPORATION OF INIDA
P& GS BRANCH: KARNAL