Haryana Marketing Board

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MARKETS
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Forms - LIC Form A

LIFE INSURANCE CORPORATION OF INDIA CLAIM FORM 'A'

(To be completed by the Master Policy Holder for claiming benefit under the Group Saving Linked Insurance Scheme on Retirement or withdrawal of a Member)

1. Name of the Master Policy Holder ____________________________

2. Master Policy Number______________________________________

3. Date of commencement ____________________________________

4. Details of the member _____________________________________

Name	Employee No./Serial No.	Category	Date of joining the scheme	Initial monthly contribution	Date of change/s in category
1.	2.	3.	4.	5.	6.

Amount of last monthly contribution	Date of exit	Due Date of last contribution	Date of payment of last contribution	Any contribution Date/Amount
7.	8.	9.	10.	11.

Signature of Master Policy Holder

LIFE INSURANCE CORPORATION OF INIDA

P & GS BRANCH:KARNAL

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