LIC Form A

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