sDP 50.000-12/12 ctrt ri,/Form No.

5074/351 0
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LIFE INSURANCE CORPORATION OF INDIA
ffi qusa/Delhi Division -lll
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Apptication for Surrender /Discounted Value
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The Sr. Branch Manager
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LIFE INSURANCE CORPORATION OF INDIA
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Dear Sir/Madam, _o rd........... :{
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Re.: Policy No. Fvg.
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* | intend to surrender my above Policy. Kindly pay me the same
*' My above mentioned policy will mature on........ ...1 intend to have it dicounted value. Kindly pay me
the same.
' rr{ftq ,/ Yours faithfullY,

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* Delete where Inapplicable Name ........:.......
T{r =Trq/ Full
qil / Address..

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Note : In case the policy is assigned, the application must be signed by the assignee. (at which cheque is to be Posted)

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Beceipt or the Surr

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surrender/Discounted value (inclusive of case Value of Bonus)
D.A.B. Refund

TOTAT Rs.
frtiT vrft mre aft rr$lless
-1P1/Loan
qrq/Loan lnterest
tq frKZPremium Due
q.S. g.?. q qqrril/Apl Debit
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vrer+tii srqdq fl al$+Es qrftq+{i +ql furq+ffi{,rqi-irqSilqcnQ rfi er& t gtt{cf VEq rq $q ffRff
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"l/ We hereby declare that lA ,le have not assigned the above Life Insurance Policy to any one nor l^^,e have dealtwith
the same in any manner, except tor any AssignmenvReassignment already registered as on date by the Life Insurance
Corporation of India orthe Insurer who insured the above policy upon due Notice. lrlA/e hereby further Declare that l^/ve have not
served on any office ofthe Lile Insurance Corporation of India any other or further notice ofassignment or reassignment in respect
of above policy, nor shall l/vve serve on any office of the said Corporation any notice of assignment or reassignment betore
payment of Loan/Su rrender Value/Su rvival Benefit"
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WITNESS:
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Fd'e ffnil
lgl ilt{/Full Rupee One Revenue Stamp
to be alfixed if Gross
SurrenderValue is Rs.500

(fiqrq! d Wsrqn/Signature of Life assured)

Son of/Wife of

NEFT MANDATE FORM

a
(t

I AccountType: Savings/ CurrenU Cash CrediVNRl

O Account No.

(Bank account number should be written from left to right)

MICR No.

IPS Code:

Mobile Number:
+ l9 1

r Emailid :
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Note: llliterate persons must atfix thumb marks ivhich should be identilied by attesting
Magistrate underthe sealof his office by a
Justice of the Peace or a Block Development officer or a Gazetted
ofticer or a principal/Headmaster of Local High School or
Higher Secondary School run by the Government or an agent
of Nattnatised ulnk oi a class I officer of the corporation or a
P::"!?,i:" qftigor of the corporalion with at least five y6ars service or by an Agent of rhe corporation who is a member ot rhe
uluo aI rne level ol Divisional Manager and above provided he/sho is lully
satisfieJ about the identity of the person (s) executing .
the form Signature in Regional Languages must be attested by a respectabte
English Knowing person. The witness aitesting the
srgnalures orthumb marks should sign the Declaration bslow:
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t} srqi E-ffiqfi fut d/orq.+r ei.pr .ryqm t I

The content of this discharge form have been explained to .....,......

..'...and he/she/they hasihave signed the same after understanding the same.

SEAL OF OFFICE

IF ANY

rneft qil Hrt ;rFI/Name of Witness............

rndfr S frcren/Signature of Witness

orqnrq oI 3fl ,/Seal Off ice

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lmportant

lf the within written receipt is signed by more than one person and payment is desired
to bs made to only ono of them thsn the
following note ofauthority must be completed and signed byallofthem before a magistrate
orto aJustice of peaceorGazetted
officer or a Block Development Otficer or a Principal/Headmasts of Local High School or Higher
Secondary school run by the
Government orAgenl of a Nationalised Bankora class-lofficer of the Corporation ora Deveiopmenr
ofiiceiortne corporation
with at least live year's service provided he/she is tully satisfied about the identity of the executants
The letter of Authoriv will
also be required if paymentisto be madetoany person otherthan the signalorios or the recerpt.
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Rs
Address

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Witness: (See introduction below) EnKilqN//Signature
T{r qrq/Fuil Name- g3r oTrq,/FullName-
T€rlOccupation TsII/Address-------
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I hereby certify that the contents of this Note of Authority were explained by me in vemacular to Shri/

agreed to payinent being made

the party or parties authorised

Signature of Witness

tl F<flefi/Full Name.....................

Instructions:
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This fetter ot authority must be signsd before a Magistrate or aJuslice of peace ora Gazetted Otficer or a PrincipayHsadmaster
ot Local High Schoolor Higher Secondary School run by the Govornmentoran Agentof a Nationalised Bank ora Class I Otficer
of the Corporation or a Development Ofricer of the Corporation with at least live years service provided hs/she is tully satisfied
about the identity ot the executants.
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This endorsement is required to be completed and signed by the attesting Magistrate or Justice of the peace or Block
Development Officer or Gazetted Otticer or a Principal/Headmaster ol Local High Schoo/Higher Secondary School run by the
Government or Officer of Nationalised BankorClass I Officerofthe Corporation ora Development Otficer of the Corporation with
at least tive yeafs servicewhen the note ofAuthority is executed byan illitrate orvernacular knowing person (s)