LIFE INSURANCE CORPORATION OF INDIA Declaration by Heirs of the Deceased A ent

a! Prea"ble #to be $sed in case of A ents %ho %or&ed for both $nit and cor'oration! ()e the $ndersi ned ************************************ #f$ll na"es of all the heirs ! all of ********************* #Hind$+,$sli"+Christian+Parsi+ Inhabitants in consideration of the Life Ins$rance Cor'oration of India #herein called (the Cor'oration-! ha.in at o$r re/$est a reed to 'ay $s 0 the $ndersi ned 1ointly 0 as the heirs of as an intestacy of ********************* #here in called (the deceased-! %ho %as an A ent of the ************************ #herein called ( The co"'any-! $' to 23st A$ $st 3456 and thereafter fro" se'te"ber 3456 %as an a ent of the Cor'oration 0 the co""ission of the 're"i$"s recei.ed in res'ect of the Policies introd$ced by the said deceased in the aforesaid co"'any and the cor'oration $nder s$b section #7! or s$b section #2! of Section 88 of the Ins$rance Act9342: as "ade a''licable to LIC of India by ;a<ette Notification dated 7=>?8>34=7 do hereby sole"nly and sincerely declare and state as follo%s @ 9 Prea"ble #to be $sed in case of A ents %ho %or&ed for Units only! ()e the $ndersi ned ************************************** #f$ll na"es of all the heirs! all of *********************** #hind$+,$sli"+Christian+Parsi+Inhabitants in consideration of the life ins$rance Cor'oration of India #herein called (the cor'oration-! ha.in at o$r re/$est a reed to 'ay to $s 0 the $ndersi ned 1ointly 0 as the heirs of as an intestacy of ******************** #here in called ( the deceased-! %ho %as an a ent of the ************************ #here in called ( the Co"'any-! $' to 23st A$ $st 3456 and thereafter fro" Se'te"ber 3456 %as an a ent of the Cor'oration 0 the co""ission of the 're"i$"s recei.ed in res'ect of the Policies introd$ced by the said deceased in the aforesaid co"'any and the cor'oration $nder s$b section #7! or s$b section #2! of section 88 of the Ins$rance Act9342: as "ade a''licable to LIC of India by ;a<ette Notification dated 7=>?8>34=7 do hereby sole"ly and sincerely declare and state as follo%s> ( Si nat$re of Clai"ant Cont>>> in 'a e97

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Prea"ble #to be $sed in case of A ents %ho %or&ed for both cor'oration only! ()e the $ndersi ned ****************************** #f$ll na"es of all the heirs! all of ********************* #Hind$+,$sli"+Christian+Parsi+Inhabitants in consideration of the Life Ins$rance Cor'oration of India #here in Called (the cor'oration-! ha.in at o$r intestancy of **************** #here in 'ay to $s0 the $ndersi ned 1ointly 0 as the heirs of as an intestacy of of ********************#here in called ( the deceased! %ho %as an A ent of the ************************ #here in called (the co"'any- $' to 23st A$ $st 3456 and thereafter fro" Se'te"ber 3456 %as an a ent of the cor'oration 0 the co""ision of the 're"i$"s recei.ed in res'ect of the Policies introd$ced by the said deceased in the aforesaid co"'any and the cor'oration $nder s$b section#7! or s$bsection #2! of section 88 of the Ins$rance Act9342: as "ade a''licable to LIC of India by ;a<ette Notification dated 7=>?8>34=7 do hereby sole"nly and sincerely declare and state as follo%s (> 3! That the deceased died on ******************* day of 7?***** That %e the $ndersi ned na"ed**************************** %o$ld be the sole heirs on the intestacy of the deceased lea.in se'arate 'ro'erty of his o%n and %e the $ndersi ned na"es ****************** are le al re'resentati.es +heirs of ******************** deceased 0 %ho %as also one of the 'ri"ary heirs of the deceased at the death of the deceased b$t died s$bse/$ently and as s$ch %e are 1ointly entitled to the final co""ission or any "oneys d$e to the a ent till the date of his death and also rene%al co""ission in res'ect of rene%al 're"i$"s