LIC Death Claim Form 3801 PDF Details

When someone passes away, dealing with life insurance can be one of the biggest tasks for the family or beneficiaries left behind. The LIC Death Claim Form No. 3801 serves as a crucial document during such poignant times. This form is used by nominees, assignees, or legal representatives to formally request and acknowledge the receipt of claim funds from a deceased's life insurance policy under the Life Insurance Corporation of India. It provides detailed fields for summarizing the policy under which the death claim is made, including specifics like the sum assured, bonuses, any applicable loans, and the net claim amount after deductions. Alongside financial details, the form gives clear instructions on how it should be completed, specifying the presence needed of an advocate, various officials, or officers during the signing. Furthermore, the inclusion of personal identifiers, such as father's and husband's names for female claimants and requirements regarding the attestation of thumb impressions, underlines the form's emphasis on precise verification and authentication. This approach not only secures the transaction for all parties involved but also outlines a clear procedural path for disbursing the death claim, ensuring that the process is as straightforward and respectful as possible during a difficult time.

QuestionAnswer
Form Name LIC Death Claim Form 3801
Form Length 3 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 45 sec
Other names lic form 3801, lic form 3801 in hindi pdf, lic claim form, form 3801 lic

Form Preview Example

Divisional Office

FORM NO.3801

Branch Office

DISCHARGE FOR DEATH CLAIM UNDER POLICY NO.

Dated

On the life of Shri/Smt

 

 

I/We

the nominee(s)/assignee(s)/legal representatives of the

above named life assured by virtue of the nomination/assignment/legal evidence of title

dated

granted to me/us by the

do hereby acknowledge receipt from

the Life Insurance Corporation of India, of the sum of Rupees(in words)

including the

amount of Bonus, in full and final satisfaction and discharge of all my/our claims and including the amount of Bonus, in full and final satisfaction and discharge of all my/our claims and demands under the above mentioned Policy on the life of the above mentioned

person, who died on

and which policy is hereby delivered upto the said Corporation to

be cancelled :

 

 

 

 

 

Sum Assured/Paid-up Value

 

 

Rs

.00

Bonus Allotted/ Loyalty Additions

 

 

Rs

.00

Interm Bonus

 

 

 

Rs

.00

Final Additional Bonus

 

 

Rs

.00

Difference of premium on account of

 

 

 

overstatement of age

 

 

Rs

.00

Refund of extra premium for Sex, DAB,

 

 

 

EPDB and Occupation

 

 

Rs

.00

Gross Claim Amount

 

 

Rs

.00

LESS

 

 

 

 

 

Unpaid instalments of premium due in the

 

 

 

Policy

year of death

 

 

Rs

.00

Late fee thereon

 

 

Rs

.00

A.N.F Debt

 

 

 

Rs

.00

Loan

 

 

 

Rs

.00

Interest on Loan

 

 

Rs

.00

Amount recoverable on account of

 

 

 

 

Understatement of age

Rs

.00

Rs

.00

Others

 

Rs

.00

Rs

.00

Total Deductions

Rs

.00

Rs

.00

NET CLAIM AMOUNT

 

 

Rs

.00

Dated at

this

day of

 

Signed by Shri/Smt

 

 

 

 

 

1 Re.

 

 

in the presence of

*

 

 

 

 

Revenue

 

 

 

 

 

 

 

Signature of witness

 

Stamp

 

 

 

 

 

 

Full Name

 

Signature of claimant/s

Designation

 

 

 

 

 

Address

 

 

 

 

 

 

 

Fathers Name

:

 

 

Husband Name :

 

 

Address

:

Notes :

(1)Payment will be made by a crossed and order cheque, if payment is desired by M.O (Net upto Rs. 1000/- only ) or a Demand Draft, it can be made at the claimant’s cost and at his/her risk and responsibility on his/her signing the following note of request.

I/We hereby request the Corporation to pay the aforesaid amount by M.O

/Demand Draft on theBank,at my/our own risk and responsibility. I/We further agree to the M.O. Commission/Bank Charges being deducted from the claim amount .

(Signature of Claimant/s)

(2)This form must be completed before (1) an advocate, (2) an Agent of the Corporation (who is a member of an Agents club at the level of Divisional Manager’s club or above), (3) a Bank Manager, (4) a Block Development Officer, (5) a Commissioner of Oaths, (6) a Doctor, (7) a Gazetted Officer, (8) a Head Master of a High School, (9) a Head Post Master or Departmental Sub-Post Master but not a Branch Post Master, (10) a Magistrate, (11) An Officer or Development Officer of atleast 3 years standing (12) A confirmed Development Officer recruited from the Agents, who were DM or BM Club Members before joining (13) A Development Officer recruited from agents who were ZM or Chairman’s club members before joining (14) President of a Village Panchayat or Local Body.

(3)If more than one person have signed the Discharge Form, the names of all the persons should be stated.

(4)A female when signing, must add her father’s as well as her husband’s name after her

own, describing herself as a daughter of Shri

and wife/widow of shri

(5)“In case the claimant affixes thumb impression or if this form is signed by more than one person and payment is desired to be made to only one of them as per the following Note of Authority completed and by all of them, the thumb impression or the signatures on the letter of authority must be attested by an Agent of the Corporation

(who is a member of the club at the level of Divisional Manager’s club and above), a Block Development Officer, a Magistrate, or an Officer or Development Officer (with at least 3 years’ service as Development Officer) of LIC or a Bank Manager of Branch of State Bank of India or of one of the nationalized banks (provided the attesting Branch Manager signs after affixing an official rubber stamp giving his name and designation as also the name and address of the Bank where he is working) or the Principal/Head Master of a local High School or Higher Secondary School run by Government. Where thumb marks are affixed, the attesting official must make the following signature under his signature :

“Shri/Smt

son/daughter of Shri

and wife/widow of Shri

has affixed

his/her thumb marks in my presence after understanding the contents thereof.”

 

 

 

 

 

 

Place

 

 

 

Date

 

We hereby authorize and request the Life Insurance Corporation of India to pay the

within mentioned amount of Rs.

.00 to Shri/Smt

.

 

Signed by the parties within mentioned in the

 

(1)

 

presence of :-

 

 

 

 

 

 

 

 

 

(2)

 

Witness

 

 

 

 

 

Signature

 

 

 

(3)

 

(Signature in Full)

Full Name :

Designation :

Address :

 

I certify that the contents of this Note of Authority were explained by me to

Shri/Smt

and he/she/they have agreed to payment being made to

Shri/Smt

the authorised party.

 

(Signature of Witness)

LIC Death Claim Form 3801 isn’t the one you’re looking for?

Related Documents