anda srgfta verse reat aar frr LUFE INSURANCE CORPORATION OF INDIA [et feer-y Sete 1/ MUMBAIDIVISIONS age ar eae DISCHARGE OF - (1) arerfeifacr fan ciferettamretter dtam Raenen / aret-sircerftra dian tifereht 25 sicola arene Paeser * CASH OPTION UNDER C.D.A. POLICY (2) Ref emar citer emetter warren capa / Per cremay Merah & siawia vega areal * MATURITY PROCEEDS UNDER TRIPLE BENEFIT POLICY. (3) srtfara wedhdie tere, tem ache aoran, dren anfhr eizaro cifersh sath sraRarer entice ereA eoremeen SHAR eT, ster ge | dir da / se te seen i TH. TASH 30 TRB Pere ee, a fereh are cen iit Ge tee a. cera ee a ee eae iene aa anata. HITS. LA ‘at 30 wfcterat feet emre | * 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) mre arte cfertionctter 50 eae ecco ze ‘aren Teen brr ere & aicrofe 50 waftere arena at eet Return of 50% Premiums under Children's Anticipated Policy. ae a Ee CL een cs eee / afer ry era org HAG TEED oe TE enced ue’. grovel aire gree ee eeerand/ yolowterel Sie mer one A wecraes | Sie, gach ere 2 enka UA ora ecigere, Frets ra eh acer yelra ea bg ae ae, Frito arent Saar a aca wel ee Beet Cea eate see Bratt vita eatery wee & | \ the Proposer/ Life Assured do hereby acknowledge receipt from the Life Insurance Corporation of India the sum of Rupees_______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) etre tte Ra ere afte ere ae ahem. “sachet are aTeefer dt ra savin tales aa apreratgane e | Cash Option which fell due for payment on under the above Children’s Deferred Assurance Policy. (2) aereronmattra RBA emer cee ec eter ertageer aa gata wear far err eh afoaroeTer ae ‘Sum Assured which fell due for payment on the date of maturity, viz__________ under the above Guaranteed Triple Benefit Policy. (©) abies wae eh ewe e/a ear eh ee les eR / peer Bee ee ee Ferarerm oer GACH ‘sense eee acerca cere shewta ates rare ig at eft Roe) erate fers aore cre STeTT UTA ean aR gt rae sieria oh.amrer.0a. tesa at 30 wieera Anticipated instalment which fell due for pe ‘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.)atta arer artfeia ciferett earch Reif Reateoraeia areca eccareen (Sear BA Ste) 50 Tes ETAT LAT. sort eer sient were rz 0 wre saree afc reat eat wegane Fareran area reexretFet ees Ratsematg Rah, sana hse rer ematfta anffererat-aoaer srreren ere 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. 2azit/2a ait Amount Payable Rs. wafer Less aerae ed / sree tier Unpaid Premium B. Rs. sreaadic aaa / Hisar Gz =e Intereston Premium — B. Utetafraddfeetse Policy Loan Rs. ceed ars | HEVTE ST Interest thereon B. Rs. sree / seared Other deductions @. Rs. faa tazaen/ gata Net amount payable &.Rs.. Sampara ater (daanpa daz) * Strike Out which are not applicable. Aish rere ees avec ot ater rete coer er Teh aie ey ee zen saree rete’ rar a brads’ aicecer sete zg ar yaeir ra ea aaa ore aetsoren rend referee Ay oTee Ia aad em, are arecioen cectadier Berane fret Roar aren art 2vensrie meres rend creer aargera Roa yaciageert git aa amTaat aT. “Afr eae ees azar sen 8 ae ch Here ree ie lata a fh ors PA aera a roar ar gach ah oer EAA, Pra Tey, a a, Hier a ort seza sacha rh a a oT apeare daresefer og &, ate a a aif er siete ales —————_— aa rare een of2wece eer 3s apr et fers cere aver ser gasfoenor a8 ag ar gpT/2a | We hereby declare that |/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 A anadt Uercerae area Goer eres ae a, ‘Hayao ater an Reh area waa acetor al rer’ | We have not dealt with policy in any other way. Rees Reaifésa eer Dated at Raiethis__afat/are day of Stoiied by Sievert meee cer eee ST in the presence of ‘erahiare earl / Bnet Bea / Signature : WY fara /ggrarat/ Full Name N | %/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) 2a s-eecieestia snare aad Bena (agratwcsrenn rare) Ret onset. wloreendt doar aris ere Roar et-sHisea een re cee ren sires sae rarest er RA ose Saf ere Tanai des Snee/ a. ai. sHaRe ao Se ager FS refer aT reer em SETA Roe Ras HME / He siisa SreTTA Tae ch OTST. ee‘gpreteal Prorat &s davai Taner wel aifferdter es rer oer cada | area seh aes Bais UE eM ranger ger doar aa ‘oe on eat ay saree farsa TENS B area wag, Fs appre ais ere Mr eroneer ger TA Tees/ TAH Ha ST ‘arararers} ue Rasen wire cen Uifereh erat B dep wore wore fra wre at oft ae /a TET ey | 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/her/them at his/her/their risk and responsibility and also agree/ to the bank/money order charges being deducted from the Policy moneys. arr/ TA / Place ‘Rai Date, Alara eee sean aertecae Reith eve 8 cea ahr cee Ras gat, HET a Mae ge sma oH rahe rr Ae ae ence at ese / a, see eA ends aM eRe. sr cree oe ea a ory & shar en ares gece eres we AY ea A rahe eat arg emcee & |e ga: Re car & 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. ) @ faanenzer/artere wiet eaerhh / diene / eeareh wea Signature/s of the Assured/claimants/s (2) erg cra Bier ich errs De RS sa gre MoT sh ae Shes AA soem meio Fa aS. ag Reg hese re et ree ta eee eh Rea acer eet ee eh ease afta, ae ae Stee 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 oer Soe eran efter fan ener Pear TARA. rey nr oe Hi ora rea Ht Ta tH signe rae oT BA | Signature in Indian languages must have the English transactions written beneath. (4) aR aha sirear em seach ordre cae seer ecalena rcite goe CeT oe SAA ARS, alse wake Rote erie ae Rb eazer ior ors ane, oe Ror ators, ze afters, saree, Par xerkecaer tren rn a et Sa grt Ree fren re err fen aa aghast chat Rote ween vee gen tare BER STH Fry eer eer stron, =e dew es sen Pret zabitier ver ena (re ecient acorn Ror eae ae af er eee sar A aa ah sre kata nf er ela en Sore HT eae aoe A) bar eats ama ene er aeTeA ert TH rents eer pen reel / mea meen ae ARTS aT STATS TT TTR A TANS. freee tei ard abgs ar erat eoran aR Pree wera ira ena eer ise ers aera ee TSS sou baer sere, wie Ree afters (A. st.) revo aia, arated ard ais ad ere ore rer sr Ser ge ag Ben ere ors Rene ch aren a Sega Roar rer Sh rg ate. eT a eee ee ae sie oh Ra ere eigen era de (ae Rs a ere es ect eect vez Brea sera, en es ay, wert ener & OT a GeaT TAT wea) ah wes RRS, ATA prensa eee eM eA a ese eT ze Reo eve 8 eens EAT TA wi feats thao ana secTare & Bret wea aT | nee