Lic Query Form

Ref : KMDO/M, Claims/LP

QUERY

FORM

To be completed by the Claimant/Policy holder under a Policy which has matured for payment but policy document is misplaced or loss and not traceable inspite of repeated diligent searches. Ref : Policy No. ________________ Loss Policy No. ________________ Date of Mat _________ Sri/Smt __________________________________ Sum Assured ___________________ 1) Under what circumstances the Policy document was misplaced or lost ? 2) What efforts have been made to trace out the policy ?

3) Has Life Assured assigned/transferred, mortgaged the Policy to any person, bank etc, for any consideration or dealt with any other manner ? If so, give particulars thereof

4) Give following information : a) Full Name of the Life Assured’s Father b) Place & date of Life Assured’s Birth c) Life Assured’s occupation at the time of taking out of the Policy d) Life Assured’s address at the time of taking out of the policy. e) Whether duplicate policy has been issued or applied for f) Name of Nomince 5) Full particulars of the person ready to join as a Surety in executing the INDEMNITY BOND a) His full Name b) His Occupation & Full Address c) Is he of sound financial status ? d) Whether related to Life Assured/Claimant Dated ________________ this ___________________ day of ____________________ 200 WITNESS of any Gazatted Officer under Office Seal Signature Full Name Occupation Address

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……………………………... Signature in full In English/Vernacular of the Claimant/Life Assured