CLAIM FORM - 1

CLAIM FORM UNDER

GROUP INSURANCE SCHEME FOR POWERLOOM WORKERS (JBY)

PART A : [to be completed by the claimant (beneficiary/nominee)]

  1.   Name of the beneficiary (member of the Scheme) IN BLOCK LETTERS  
  2.   Address of the beneficiary (member of the Scheme) :  
  3.   Name of Father/Husband :  
  4.   Registration No. :  
  5.   Date of Entry into the Scheme :  
  6.   Name and Address of Nodal Agency :  
  7.   Details of Nominee (in case of death) : Name
& Address 		aaaaaaaaaaaaaaaaaaa  
Relationship :  
  8)   If the claim is for death, please give the following details/documents :
a) Date of death :  
b) Age at death :  
c) Place of death :  
d) Cause of death :  
e) Certificates attached (Please x where applicable : Natural death - Death Certificate
Accidental death - Death certificate, FIR, Police inquest report, postmortem & police Conclusion report (Original)
9 If the claim is for permanent/partial disability, please give the following details/documents :
Certificate from Medical Practitioner, Clarifying the extent & nature of disability
10) Details of the Bank A/c. of the claimant :
A/c. No. Name & Address of Bank





I hereby declare that all the above particulars are true and correct in every respect.


Place: _________________  
Date: __________________ ( Signature of claimant )


Witnesses (Names & Signatures) :


Name Address Signature with date & Place
1.

2.

   


PART B : (to be completed by the Nodal Agency)

Certified that the above information is correct in every respect. Claimant named above was a duly registered member of the Scheme/nominee of the member with Regn. No. ________________________ and fulfills the criterion for making the claim.



SEAL __________________________________________
Signature of Authorized Signatory of the
Nodal Agency/Master policyholder