Form for claiming payment of a Post Office Insurance Policy

(To be used when claimant is a person other than the policy-holder)

1. Full Name of the Insured : ………………………………………………………..

2. Number of Policy :………………………………………………………..

3. Value Of Policy : ………………………………………………………..

maturity of Policy

4. Exact Date of _____________________ : ………………………………………...

death of the Insured Person

5. Cause of death of the Insured Person : .….……………………………………

6. Full name of the claimant : ………………………………………………………...

7. Age of claimant : …………………………………………………………

(If the claimant is a minor, the person who represents himself to be the minor's guardian should fill up the entries 10 to 13 overleaf.)

8. Claimant's relationship to the Insured .

How can it be proved ?

9. Description of documents in support of claim : ……………………………………….

Note - If claimant has obtained probate of the will of

the insured or certificate of succession or letters

of administration ,the documents or certified

copies should accompany the form . : ………………………………………

Note .- The answer to the following must be filled by a person who represents himself or

herself to be the guardian of a minor who claims payment of a policy.

10. Are you an adult relative of the minor ? State your relationship ……………………….

11. Is the father or mother of the minor deceased ? ……………………………………..

12. If you are not the father or mother of the minor,

have you been appointed guardian of the minor

by will or deed or under any enactment in force

in India ? Produce the documents to support

your claim.

13. Does the minor reside with you or is he maintained by you ? ………………………….

……………………………………………………………………………………….

Station ……………….. ………………………………………

Dated ………………… Signature and address of the claimant or

Other persons representing himself or

Herself to be the guardian of the minor.

FOR USE UNDER INSTRUCTIONS FROM THE POSTMASTER GENERAL

Certified that I have personally enquired into the truth of the above statements and the signature of the applicant is genuine.

Signature of Enquiring Officer