-0411
SDP20,000
Folders
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cqe {i/Form No. 5074/3510
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LIFE
INSURANCE
CORPORATION
OFINDIA
Rd
rroga,/Delhi Division -III
ersqqur/Tdr{rd
IFq + srefrTqe
Application for Surrender /Discounted Value
qRs €Trcrlqirffr.F
The Sr. BranchManager
ern/Phce.
LIFEINSURANCE
GORPORATION
OF INDIA
slrut $Tqfcrqd./erancnUnitNo...................
ffi1-5/Date.
qrgfrq #{q *fl furq
frq relesZqrrY€r,
Dearsir/Madam'
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. Ecft{q .,q....................
Re.:PolicyNo.
*
*
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I intend
to surrender
myabovepolicy.Kindlypaymethesame.
My abovementionedpolicywill matureon...........................1
intendto have it dicountedvalue.Kindly
pay me the same.
*
d ar.1qd sS ore tr
*
Deletewherelnapplicable
rr{frq / lYoursfaithfully,
EGilSIT
Signature
Wr.Trq/FultName
tl-cTl,/ Address.
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w srgeFfl d rsren di qrtrqI .
Note : In casethe policyis assigned,the application
mustbe signedby the
sr1qrf d q{""""'
(q-di+o, f+ffiTqrarErnt)
(at which chequeis to be posted)
Eqn q,1qrfr$
6 sqfifu {fl + g,rdrc6T sT{
Receiptor the Surrender/Disdounted
Valueof policyNo...............
.....,..................on
Rs.
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(vrqi { ga rnq qftd)
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"'i""".'";"';'
do herebyacknowledge
receiptfrom Life InsuranceCorporatlon
of Indiathe sum of
FIc
beingthe Gross/SurrenderlDiscounted
Value includingCase Value of Bonusof above mentionedpolicywhichis
herewithdeliveredupto the said corporationto ue cJnceiteo.tn *itness, whereofthe presents
are subscribedby me/us
at
surrender/Discounted
Value(inclusive
of caseValueof Bonus)
D.A.B:Refund
R s ,. . . . . . . . . . . . . . . . . . . .P
. ... . . . . . .
R s .. . . . . . . . . . . . . . . , . . . .P. ... . . . . . .
TOTAL Rs..............................p.
fuq vtfu sTe ff rpff/Less
4t1/Loan
rro/Rs
aryu/LoanInterest
so/Rs.....
fu frqnremium Due
So,/Rs.
q.fl. \'f,. qr qq[T|/Apl Debit
so/Rs..
sria rmrl/x- charge
fr{A {rfu/Net AmountpayabtesoTRs
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"l / We herebydeclarethat llWe havenot assignedthe aboveLife InsurancePolicy
to any one nor lAffehavedealt
with the same in any manner,exceptfor any AssignmenVReassignment
alreadyregisteredas on date b.ythe Life Insurance Corporationof lndiaor the Insurerwho insuredthe abovepolicyupon due-Nlotice.
lAffe herebyfurtherDeclar:e
that l/
We have not servedon any officeof the Life InsuranceCorporationof Indiaany other or turtnei
noil;;i iJgnr"nt o,.
reassignment
in respectof above policy,nor shall lAtVeserveon any officeof the said Corporationany notice
of assignment or reassignment
beforepaymentof Loan/Surrender
Value/Survival
Benefit',
WITNESS:
uR ga cm-q500 s. r)
srf6ddlrn:orrrftS
F6E arrrRi
ERlItrt/Signature
g
il{/FullName.
qEqrq/Occupation.
FlupeeOneRevenue
Stamp
lo be affixed if Gross
Surrendei
Valueis Rs.500
tltll/Address
(ffqted d fwrenr/Signatureof Lifeassured)
SonofAlVifeof
2
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,
' Note:.:Jllitrate
persons
mustafixthumbmarkswhichshouldbe identified
by
attesting
Magistrate
under
the
seal
ol r,i, otrt"l
by a Justiceof the Peaceor a Blockoevetoprnent
o#i.lr-"i"tazetteo officeroia eiincipat/Headmaster
of
Locat,High.
schoolor Highersecondery
run
uv the Government ;;;;;i;
N;";"ti.eo
aank
Ftgor
or
a
ctass
I
officer
of rhe
corporationor a Deveiopment
otficerof th'bcqrporationwith";
at teasifiveyearsserviceor oy an Agentof the corpoiaiion
who is'a memberof the ciub at the leveltt oioision"rnaanageiand
aboveprovidedhl/she is fullysatisfiedaboutthe
idenlityof the person(s) 6xecuting
theform',signature
in negionatLanguages
ru.io"
by a respectabre
English,
KnowlngpelsonThewitne,ss
attesting
tne signltuiesor tnu-riiriarksshoutdsignthe Dectaration
"tt"sted betow:
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The contentof this dischargeform have been exprained
to
,
'
,
and helshe/fheyhqs/havesigned,thesame after understanding
the same.
SEAL OF OFFICE
tr Auv
' .,,
gnff or gc ;na/Name of Witness
gnfl d Eiilerr/Signatureof Witness
qrr*/Occupation
tlct/Address
o.rqffiq or getzSeat Office
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lmportant
lf thewithinwritten*t"-'ll
onepersonandpayment
j:.:9L?9,bymore.than
is desiredto be madeto ontyoneof themthen
thefollowing
noteof authoritiriust ne comfeledandsignedby altot them
beforea magistrate
or to a Justiceof peaceor
Gqzetted
officeror a Block-Devetopment'ori."1
or a Frincipal/Headmaster
of L6catHign_scrroot
or Highersecondary
schoolrun'bythe Governmgnt
or Agentof a Nationatised
Bank
iil" corpor"tionor a Deveropmenr
officer of'the corporationwith at l6asttru"
"r;;;r;'<iiii#"t
v""i.-.";"i";;;;;d.d.
he/shsi. turrv,"ti.ti"o aboutthe ident*yof the
letterof Authoritv
willalsobe required
it paym5nii. to n* madeto
p"oon otherrhanthesignatories
or
iff?:l$::.the
"nv
Tem/Phce
futo/oate
(slfo,rt crq fuq Eg aqfu.?F'ltrq)
TE qfu qr qRir{ii i frq o1 Eqfufr C affier frtqt
Witness:(See introductionbelow)
Effiefi/Signature
{c +r/Full Name
ftr arrlFull NameF----------qil,/Address -------------
@
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b y m e i n v e r n a c u l a rt o s h r i i
I h e r e b y c e r t i f y t h a t t h e c o n t e n t s o f t h i s N o t e o f A u t h o r i t yw e r e e x p l a i n e d
"""""""'the
has/haveagreedto paymentbeing made to."""""""
party or partiesauthorised
Signatureof Witness
$ rgmrzrull Name......'
lnstructions:
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peace or a Gazettedofficer or a Principal/
This letter of authoritymust be signed before a Magistrateor a Justice of
Bank
or an Agentof a Nationalised
the
Government
Headmasterof LocalHigh school or HigherSecondaryschool run by
provided
years
service
five
least
at
with
Corporation
of
.the
ofiic"r
or a Class I ofiicer of the Corporationor a Development
he/sheis fully satisfiedabout the identityof the executants'
: qfr 3Tffi
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ett* fts rrr Etus ftuors qfffi
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q1 qrq15Ed ilo d \rd-€ w ft{rq d qarq *oft 3TfDmTA
ffqrtrq d sq','rd/cqFilrqrc6
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9-6l d erfl lrt.Fr E<TIenf+t
or Justiceof the peaceor Block
Magistrate
andsignedby the attesting
to be completed
is required
Thisendorsement
Schoolrunby
secondary
of LocalHighSchool/Higher
officeror a principal/Headmaster
officeror Gazetted
Development
officerof the
Development
a
or
Bankor class I officerof the corporation
or officerof Nationalised
the Government
knowing
vernacular
or
illitrate
an
by
is
executed
withat leastfive year,sservicewhenthe noteof Authority
Corporation
person(s).