Understanding the intricacies of filing a claim with the Life Insurance Corporation of India requires familiarization with specific forms, one of which is the Form No. 3783A. This document is crucial for claimants legally entitled to the policy moneys following the demise of the insured. The form serves as a comprehensive claimant's statement, detailing every essential aspect of the claim process. From providing personal data about the claimant and the deceased to specifying the relationship with the deceased and the nature of the claim (be it as a nominee, assignee, executor, administrator, trustee, or beneficiary), the form covers all bases to ensure the legitimacy and completeness of the claim. Additionally, it gathers detailed information about the deceased, including the place and date of death, the final illness and its duration, the cause of death, and the deceased's last occupation and residence. Moreover, if the deceased held other policies, details of these must also be included. Importantly, the claimant must sign the form, authorizing any physician or hospital that attended to the deceased to share medical information with the Life Insurance Corporation, thereby waiving the right to medical confidentiality in this context. This authorization is crucial for the processing of the claim, as it allows the insurer to assess the claim's validity thoroughly. Lastly, the form stipulates that it must be countersigned by an individual from a specified list of professionals, adding an additional layer of verification to the claim.
| Question | Answer |
|---|---|
| Form Name | Form No 3783A |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | lic death claim letter format in tamil, lic claimant's statement form, how to fill up lic death claim form, lic 3783 a form download |
|
FORM NO. 3783(A) |
|
LIFE INSURANCE CORPORATION OF INDIA |
Divisional Office |
Branch Office |
……………………….. |
………………………… |
|
CLAIMANT’S STATEMENT |
(To be filled in by person legally entitled to the policy moneys).
(All answers to be filled in legibly. Answers must be given in words, strokes of the pen or dots or dashes cannot be accepted as replace)
In connection with claim under Policy No. …………………for Rs.…………………………
On the life of ……………………………………………………………………………………………….
(Insert full name of the deceased)
I as the claimant under the policy make the following statement:
1.Particulars regarding the claimant:
i)Name of the claimant…….
ii)Age …..
iii)Tel. No. ……………
iv)Address: …………………………………………………………………………………
…………………………………………………………………………..
v)Relationship to the deceased Life Assured: ………………………………………….
vi)Nature of Title under which the claim for policy
Money is submitted, viz. Nominee, Assignee, Executor,
Administrator, Trustee or Beneficiary ………………………………………………….
_____________________________________________________________________________
_____________________________________________________________________________
2.Particulars regarding the deceased Life Assured Shri/Smt. …………………..
i)Place of death of the Life Assured:
ii)Date of death: ………………… Exact time of death ……………………A.M./P.M.
iii)Age of the Life Assured at death : …………………………………………………..
iv)Duration of last illness ……………………………………………………………….
v)Immediate cause of death : …………………………………………………………..
vi)Last Occupation of the Life Assured : ……………………………………………….
vii)Last address of the Life Assured : ……………………………………………………
viii)Full name of deceased’s father : ……………………………………………………..
3. Particulars regarding the other Policies on the life of the deceased:
Pol. No. |
sum Assured Name of |
Date of commencement whether with Double |
|
issuing |
Accident or Extended |
|
Office |
Disability Benefits. |
_____________________________________________________________________________
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
_____________________________________________________________________________
I, ………………………………………… do hereby declare that the estatement made
hereinabove is true in each and every respect.
Notwithstanding the provisions of any law, usage, custom or conuention for the 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, I hereby authorise the physician or Hospital who has attended upon or examined or treated the aforesaid deceased life assured for any ailment or illness to divulge any knowledge or information regarding the deceased’s state of health which he/they may have acquired whether before or after the policy was issued by the Corporation, to the Corporation, its Offices and legal advisers or in any Court of Law.
Declared at …………………….this………………day of…………………….19 Before me.
________________ |
Signature/thumb impression of the Claimant |
Signature of witness |
Full Name :………………………………….. |
|
Designation : ………………………………… |
|
Address : ……………………………………. |
|
Tel. No. ……………………………………... |
Note : * (This statement must be countersigned by (1) an Advocate (2) an Agent of the Corporation (who is a member of an Agent’s club at the level of divisional Managers’ club or above), (3) a Bank Manager, (4) a Block Development officer, (5) a Commissioner of Oaths, (6) a Doctor, (7) a Gazetted Officer, (B) a Head Master of a High School, (9) a Head Post Master or Departmental
Development Officer recruited from agents who were ZM or Chairman’s club members before joining or (12) President of a Village Panchayat or Local Body.
IF THE DECLARANT SIGNS IN VERNACULAR OR AFFIXES THUMB IMPRESSION, THE WITNESS SHOULD ALSO SIGN THE FOLLOWING DECLARATION:-
CERTIFIED THAT THE CONTENTS OF THE FORM WERE EXPLAINED TO THE DECLARANT IN VERNACULAR AND HE/SHE HAS AFFIXED HIS/HER SIGNATURE/THUMB IMPRESSION HERETO AFTER FULLY UNDERSTANDING THE SAME.
Signature : ……………………………….
Full Name : ………………………………
Designation : …………………………….
Address : ………………………………...
Tel. No. ………………………………….