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ctrt ri,/Form No. 5074/351

LIFE INSURANCE CORPORATION OF INDIA

qusa/Delhi Division -lll eicqdq/wrqd loq d meiil qt Apptication for Surrender /Discounted Value
qRG6 Irail gr*I?F The Sr. Branch Manager

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LIFE INSURANCE CORPORATION OF INDIA

Sir/Madam,
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Er6rqrl Te{r tnq iF'it=TI qrgtrl Rt qqqr f* strol gqdn env t I | intend to surrender my above Policy. Kindly pay me the same ...1 intend to have it dicounted value. Kindly pay me My above mentioned policy will mature on........
the same.

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Yours faithfullY,

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Delete where Inapplicable

Name

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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)

TOTAT Rs.

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qrq/Loan

lnterest

tq frKZPremium Due q.S. g.?. q qqrril/Apl Debit

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charge

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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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Gross

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Rupee One Revenue Stamp

to be alfixed if

SurrenderValue is Rs.500

Wsrqn/Signature of Life assured)

Son of/Wife of

I AccountType: Savings/ CurrenU Cash CrediVNRl

Account No.
(Bank account number should be written from left to right) MICR No. IPS Code:

Mobile Number:

+ l9 r
Emailid
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cte: 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 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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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

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of Witness

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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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Witness: (See introduction below)

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hereby certify that the contents

of this Note of

Authority were explained

by me in vemacular to

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agreed to payinent being made

the party or parties authorised

Signature of Witness

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

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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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lrro-t rrnen d-fl qGc I 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)