Annexure I FORM NO. 3783 Claim Form A' Life Insurance Corporation of India
Annexure I FORM NO. 3783 Claim Form A' Life Insurance Corporation of India
Annexure I FORM NO. 3783 Claim Form A' Life Insurance Corporation of India
CLAIMANT’S STATEMENT
(All answers to be filled in legibly. Answers must be given in words, strokes of the pen or
dots or dashes cannot be accepted as replies)
(vi)
Nature of Title under which the claim for policy money is submitted viz:
Nominee, Assignee, Executor, Administrator, Trustee or
Benefciary………………………
_____________________________________________________________________________
6. Names and addresses of the doctors consulted during the last three years stating against
each name the complaint for which he was consulted and the date or dates thereof;
1.
2.
3.
Notwithstanding the provisions of any law, usage, custom or convention for the time
being in force prohibiting anu Physician or Hospital from divulging any knowledge or information
acquired by him/them in attending upon or examining a person on the ground of secrecy, I hereby
authorise the Physician or Hospital who has attended upon or examined or treated the aforsaid
deceased life assured life assured for any aliment or illness to divulge any knowledge or
information regarding the deceased’s state of healthe which he/they may have acquired whether
before or after the policy was issued by the Corporation, to the Corporation, its offices and legal
advisers or in any Court of Law.
Designation………………………
Address ………………………….
…………………
(This statement must be countersigned by (1) an Advocate, (2) an Agent if the Ciroiratuib
(who is a member of an Agents’ club at the level of Divisional Manager’s Club or above), (3) a
Bank Manager, (4) a Block Development Officer, (5) a Commissioner of Oaths, (6) a Doctor, (7) a
Gazetted Officer, (8) a Head Master of a High School, (9) a Head Post Master or Departmental
Sub-Post Master (but not a Branch Post Master), (10) a Magistrate, (11) An Officer or
Development Officer of atleast 3 years standing or confirmed Development Officer recruited from
the Agents, who were DM or BM Club Members before joining or Development Officer recruited
from agents who were ZM or Chairman’s Club members before joining or (12) President of a
Village Panchayat or Local Body.