FORM OF CLAIM FOR SURVIVAL BENEFIT DUE ON ANTICIPATED ENDOWMENT ASSURANCE POLICY

1. Policy No. : _____________________________

Date of Acceptance : _______________________

2. Date of Survival Benefit due :

3. Name and address of Insurant : ____________________________________

(In block letters)

4. Designation and address of :

(i) Pay Disbursing Officer

during last six months.

(ii) Pay & Account Officer

5. Name of the Post Office : ______________________________________

at which premia were

paid during last six months.

6. Name of Post Office through : _______________________________________

Which payment of maturity

Value is desired.

Documents attached :

Policy Document.

Premium Receipt Book.

Certificate of Pay Disbursing Officer regarding recovery of premia from pay for the last six months.

Date : Signature of Insurant

Telephone No.

Office :

Residence:

______________________________________________________________________________________