(To be completed by the Master Policy Holder for claiming benefits under the group Saving Linked Insurance Scheme on death of a member)

1. Name of Master Policy Holder_____________________

2. Master Policy No. _____________Date of Commencement ___________

3. Full name of the deceased employee ______________________________________________

4. Assurance No./Sr.No. in the list of members__________

4.(a)name of the office(DDO) where Deceased was working at the time of joining the scheme _____________________

5. Date of Birth____________________________

6. Date of joining the scheme_______________________

7. Date of joining the service_______________________

8. Category___________________________________

9. Date of Death__________________________________

10. Amount of Life Insurance cover on the date of death__________________

11. Amount of monthly contribution____________________ Risk Plan ___________________ Saving Plan ___________________

12. If there has been any change/s in the monthly contribution during his membership indicate the date of changes and the revised contribution/s ________________________________________

13. Amount of last monthly contribution________

14. Due date for payment of the last monthly contribution(indicate day, month and year ______

15. The date on which the last contribution was paid to the corporation_____________________________________

16. Are there any gaps in premium, and if so, give full particulars thereof_____________________________________

17. Cause of death____________________________________

18. Nature of proof of death (please enclose original death registration certificate)____________________________________

19. Was the member in the service of the employer on the date of death_________________________________________

20. Name of the Beneficiary and relationship with the member______________________________________

21. Additional information in case death has taken place within 3 years of date of joining the scheme.
a) Was the member absent on the date of entry into the scheme (if so, give details of leave i.e. period of absence, cause of absence, how the absence was treated by the employer and date of resuming duties)
b) Whether the contribution of the member was included in the monthly remittance for the scheme as a whole in the first month . Give details of amount and date of payment to LIC
c) The date of the Authority -cum-declaration form signed by the employee.
d) Was the member alive on the day the salary was disbursed and out of which the deduction of contribution to GSLI scheme to cover the First premium was made by the employer.