When you are starting a new business, there are a lot of forms and documents you need to fill out. One of the most important is Form 3783A. This form tells the IRS about your new business, and what type of entity it is. Filling out this form correctly is essential, so make sure you have all the information you need before you begin. The IRS has a lot of requirements for this form, so be sure to read them carefully. If you have any questions, don't hesitate to ask an accountant or lawyer. Filling out Form 3783A correctly can save you a lot of time and money in the long run.
| 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. ………………………………….