GP.S.795/15—lOOOONos.
STATE INSURANCE DEPARTMENT J&K SRINAGAR
CLAIM BY MATURITY SECTION "A"CONCERNED
Statement to be Completed by the Ofticial
I
Claim under Policy No ....on the life of Shri
(This is how the life assured is described in the Policy)
1. Name ofthe official
2. Designation
3. Address
4. Father's name
2. Please confirm by reference to official records
that the official described against Question I
is the same as the life assured described at the
top ofthis Form.
3. Is the life assured in Government Service on
this date ?
4. (a) Please mention the month from the pay of (a)
which the latest premium recovery has been
made with reference to try. Vr. No. and date.
(b) Mention the amount of premium recovered (b)
from it.
(c) Name ofTreasury operating upon by (c)
present D. D. O.
Please state whether Policy Certificate is
attached herewith ?
Note The claim can be considered only on produc
tion ofthe Policy.
5. Confirm that recovery was effected continuously
for the last 3 years.
Certified that the above particulars are correct.
Countersigned by next higher authority if
D.D. O. is himself insurant
Signature of Drawing/Disbursing
Officer
G.P.S(DTP-Urdu)876/18-4200 No's
GOVERNMENT OF JAMMU AND KASHMIR
J&K FUNDS ORGANISATION KASHMIR
DISTRICT FUND OFFICE/(S.L.I Wing )
Claim by Maturity- Section 'B'
STATEMENT OF CLAIM TO BE COMPLETED BY THE CLAIMANT
Claim under Policy No. on the life of Sh.
(This is how the life assured is described in the Policy)
1. Please give your name,occupation
Name
and present address
Occupation
Address
Fathers's Name
2. Are you the same person as die life assured
who is described at the top oftiiis Form?
3. When did you cease to be in Government
service?
4 Please give particulars of the latest premi^
paid.
5. In what capacity or by what title do you claim
the Policy money? Please state whether you
are producing the policy alongwith the Form?
Note:- The claim will be considered only
on production ofthe Policy
I do here by solemnly declare that the above statemente and answers are correct.
Solemnly declared and signed before me on
the day of . 20
Signature and Designation of Attesting Authority/DDO Signature ofCiaimant
SEAL
G.P.S. 988/14-5000 Nos.
STATE LIFE INSURANCE
ESSENTIAL CERTIFICATE FROM THE CONCERNED D. D. 0.
IN RESPECT OF S. L I. PAYMENT CLAIM
This is certified that no such claim on account of S. L. i. has been preferred to State Life Insurance Srinagar in
favour of Sh/Mrs. holding Policy No. from the date of
maturity i.e till date. Further it is also certified, that the Insurant has made the following Poiicy/ies with
theState Life Insurance Srinagar for the Sum assured of Rs. during the tenure of his/her
Service from to
S.No. Application No./Policy Sum Assured Date of maturity
No. .
01. Rs.
02. Rs.
03. Rs.
Out of these policy/ies sum assured policy of Rs. matured on and is /are
surrendered for payment at present. It is also certified that the Insurant as named above in this certificate has not made any
other policy except the above one/s with the State Life Insurance and the slab limit of the policy/ies do not exceed to
Rs.36000/- in total.
Drawing & Disbursing Officer
Seal & Signature
G.P.S. 988/14-5000 Nos,
STATE LIFE INSURANCE
ESSENTIAL CERTIFICATE FROM THE CONCERNED D. D. 0.
IN RESPECT OF S. L 1. PAYMENT CLAIM
This is certified that no such claim on account of S. L. 1. has been preferred to State Life Insurance Srinagar in
favour of Sh/Mrs. holding Policy No. from the date of
maturity i.e till date. Further It is also certified that the Insurant has made the following Policy/ies with
theState Life Insurance Srinagar for the Sum assured of Rs._. during the tenure of his/her
Service from to
S.No. Application No./Policy Sum Assured Date of maturity
No.
01. Rs.
02. Rs.
03. Rs.
Out of these policy/ies sum assured policy of Rs. matured on and is /are
surrendered for payment at present. It is also certified that the Insurant as named above in this certificate has not made any
other policy except the above one/s with the State Life Insurance and the slab limit of the policy/ies do not exceed to
Rs.36000/- in total.
Drawing & Disbursing Officer
Seal & Signature
