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Forms - 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/s in 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


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