FORM OF CLAIM FOR MATURITY VALUE OF POSTAL ENDOWMENT ASSURANCE POLICY

1. Policy No. _____________________________ Date: _______________________

2. Date of Maturity :

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 premiums 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.

Loan Repayment receipt Book.

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

 Date : Signature of Insurant

Telephone No.

Office :

Residence:

______________________________________________________________________________________