‘slay - orga — ANNEXURE - 1
wa ®. 3783 (qurea)
‘Bra a HHH w, F, No.3783 (Rev.)
(seh. ara FH &) CLAIM FORM ‘A’
sre ferry
Mans! Deision “1 ore erates
Branch Office.
-SRERTA wer / ER BTW / CLAIMANT'S STATEMENT.
(ro ene ene erie FRONT aR eA)
(ene 4 AR oF TY rE AAR I HT TE)
(To be filled in by the person legally entitled to the Policy moneys)
(ad ook TST ere, TAR ria eeTA. Sear ig far Var hare TTR ATT.)
(SR Ser ere fered one Tee eet 4 AA OTA aeG| em & Fer, forg a aa see OT a eo Al BH oT Tah)
(All answer to be filled in legibly. Answers must be given in words. Strokes of the pen or dots or dashes cannot be accepted as replies)
ar agers B.A
(q@re gi ia)
3 atic,
= 3 ha wea afer
(aes aor a fered)
a ft aia trons a a a
In Connection with claim under policy No. —-—__________ for Rs.
on the life of.
(Insert full name of the deceased)
Rata sent area ater Geter Part ae, Heh & aE & WTF Fes ae sa Zl
|, as the claimant under the policy make the following statement:
1) artanrdaeh anfett - aren & fare H flawt- Particulars regarding the claimant:
|) emer ara / ardare a1 ar / Name of the Claimant.
i) wa/ mg /Age il) RAAT. / Tel. No.
iv) Ter/ Get /Address,
vere are ae
aa dite 3 wry
Relationship to the deceased life assured
vi) Sfertten eater earicaren roe / Fa: ae, VAGAAAM, Perea, were, Reaet ia ere
ate ae rs trier a a fg arg rer, ta a, sh, Per, ee, =a a
‘Renita
Nature of Title under which the claim for policy money is submitted viz : Nominee, Assignee, Executor, Administrator,
Trustee of Beneficiary
2) Fa atta aafrsiah aaeite
‘Rattan & Faved aT Particulars regarding the deceased life assured.
Ah sere ShriSmt.
1), ier eave ee Bem
ter dag ae
Place of death of the life assured
(PTO)ii) yey Reales / Ry Af / Date of death.
arash Petre tas / ey ar dts wT / Exact time of death
alg / ar arsen re: ERE: AM / PM.
ii) Be Ar aa ae
Be wr den sh arg
Age of if assured at death
iv) sae SoM FET
cafe et aay
Duration of las ness.
Immediate cause of death
vi) Sie eafeeren sree rere
en a sift ATT
Last occupation of the life assured
vii) Sifter eafeeren sree Te
er oF sffer aT
Last address of the life assured
vi) rer af et at
rer Rev aT RTA
Full name of deceased's father
3)
5)
ye Safer TET SA MRA maf ace Be Arar oe area Safer & fave a fear
Particulars regarding the other Policies on the life of deceased :
Policy No. | SumAssured | Name of issuing Office
& Servicing Branch
Siert 2oran/ Sat eT
‘ifort a. Star | wrt ara / ort ae are
ert aeratt ‘preter en Sar IAT wT A
sare Reta
ore ot Fae
Date of
Commencement
Whether with Double Accident
or Extended Disability Benefits
{|
a) Tete Se aeearacereh HH et APT ere aoeaT Sehr?
Bae 9 eae She 7 aH wa Gea rors wa TH A?
When did the deceased first complain
of being not in usual good health?
b) SmaSar aa Sear START ese
es ara feast Rrra BE
Nature of illness then complained
IaCoT STOTT GTA OTT terse feterewtA a
saa Se 5 wr PAPC Be aT |
‘The names of medical attendants during the last illness.ae
6. Fem ae asia ater een Seren, aren As Serahta Paterna Ta ani qe. ete Ferment aTaIys Teo Serer THT
wae anf cute fetter Fer.
fae ai ae & aver yer 4 form Pafeoceeet & serref ferem srerar Pease aerg BY, Tre aA Ste ga ce eee Bs aA RRrewrTT
‘sem fang 1g seraet she ere FA an fae arg
Names and addresses of the doctors consulted during the last three years stating against each name the complaint for
which he was consulted and the date or dates thereof.
ee Cera FA Paeoeere | Serer aia aie aT oe aa eer
emg SA a Fe ar AA Fefascereey ar orererct & rr ote a Rraraa & fret
Date or Dates of consultation Name of the Doctor or Hospital Nature of complaint
and address
1
2
3.
hus Em Srey eh RANT
Bae dae Rar ate aac ee ta.
a eS eet exe aoe
fo or fra SW wh wet & ae wh oe S Ta
.do hereby declare
thal a salorenis rca Teoh obove are Fun Teach end every Teepect
ort rere ene SATE EI aH ATA aT EA eT et AT eae err FHCRC aT STMT
HTT TAA AT TRH HA HLTH SA TS SOAR A AN TTA START, FT TFA GET AN RS HAT STI AY ATT
aI STA DATA ST CAT TIAA PTY SARITA HAN FT TOT ON HT SATA MTA A APSA TT
domme ar vier atte PERCE) wr ee rere BEA one A Aeris car arafery care arate Teorey Pat STAY
‘aera eatery as ava A aTgeT Be aT.
‘ee oh Fee, ere, HR ar Rear sve ret sees HT Teas TRY eT A APT aT HTT BY PAT 3 STIR
oe feet cafes oA ts See oe re BE SATEEN a eT aA & fry ahat aeea ay at A Taga Sa Patera ar sree gH, HTT
sear phere a Prt et er fe itera ae rer, renee Fr eae eer oh A ee a TAT
Seva Ha rer Hae aT A TA Be TT aT mT HA wy, es Pe, era retort he FARR ere a fee AM a ay STAT
wma!
"Notwithstanding the provisions of any law, usage, custom or convention forthe time being in force prohibiting any physician or Hospital
from divulging any knowledge or information acquired by him/them in attending upon or examining a person on the ground of secrecy. |
hereby authorise the physician or Hospital who has attended upon or examined or treated the aforesaid deceased life assured for any
ailment oiliness to divulge any knowledge or information regarding the deceased state of health which helthey may have acquired whether
before or after the Policy was issued by the Corporation, to the Corporation, its offices and legal advisors or in court of law.
feat ai-2000 Taree
wr fete e-2000 Famer eh
Declare at this —___dayof______20 _ before me.
ardent werent / seroaret Prenety -”
waar & semen / sis & Fre
Signature / Thumb impression of the claimant
Ber / eA ie giare/ quam
Dectare at, this. Full Name
nnn amine Ai 28. ATE ae BI / 3 Designation.
cr 2000 HR aerate ‘Tat / Fa Address.
Dated at. this
Day of 20 __ before me
Remit w/ Tel. No.
‘ereftarerstt eararet / ret & eee.
Signature of Witness (ero)