{"id":2281,"title":"दावेदार का बयान / CLAIMANT'S STATEMENT","purpose":"claim","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/form-no-3783a","sha256":"4c69fdff2e9782d83e80e3a3d7b1b13f7d0d5ecddae415c4f0442401a2d19537","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for making a death claim on a life insurance policy beyond 3 years from the date of risk or revival. It is to be filled by the person legally entitled to the policy money (claimant).","notes":["All answers must be written clearly in words; pen strokes, dots or dashes are not accepted.","This statement must be countersigned by one authorized person from the listed categories (e.g. Advocate, Bank Manager, Doctor, Gazetted Officer, etc.).","In case of dispute, the English version of the form shall prevail."],"title":"दावेदार का बयान / CLAIMANT'S STATEMENT","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Particulars regarding the claimant","fields":[{"help":"","type":"text","label":"दावेदार का नाम / Name of the Claimant","options":[],"required":null,"pdf_field":""},{"help":"in years","type":"number","label":"आयु Age","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"दूरध्वनी क्र. Tel. No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"पता Address","options":[],"required":null,"pdf_field":""},{"help":"describe your relationship to the deceased","type":"text","label":"मृत बीमेदार से सम्बन्ध Relationship to the deceased life assured","options":[],"required":null,"pdf_field":""},{"help":"specify your legal title for claim","type":"text","label":"स्वामित्व का प्रकार जिसके अंतर्गत पॉलिसी राशि के लिए दावा प्रस्तुत किया गया, अर्थात-नामांकित, अभ्यर्थी, निष्पादक, प्रशासक, न्यासी या हिताधिकारी Nature of Title under which the claim for policy money is submitted viz : Nominee, Assignee, Executor, Administrator, Trustee or Beneficiary or Appointee","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Particulars regarding the deceased life assured","fields":[{"help":"","type":"text","label":"बीमेदार की मृत्यु का स्थान Place of death of the life assured","options":[],"required":null,"pdf_field":""},{"help":"date of death","type":"date","label":"मृत्यु तिथि / Date of death","options":[],"required":null,"pdf_field":""},{"help":"select AM or PM","type":"choice","label":"मृत्यु का ठीक समय Exact time of death प्रातः अपरान्ह: A M/ P M.","options":["A M","P M"],"required":null,"pdf_field":""},{"help":"in years","type":"number","label":"मृत्यू के समय बीमेदार की आयु Age of life assured at death","options":[],"required":null,"pdf_field":""},{"help":"in years","type":"number","label":"अन्तिम बीमारी की अवधि Duration of last illness","options":[],"required":null,"pdf_field":""},{"help":"state the immediate cause","type":"text","label":"मृत्यु होने का तात्कालिक कारण Immediate cause of death","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"बीमेदार का अंतिम व्यवसाय Last occupation of the life assured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"बीमेदार का अंतिम पता Last address of the life assured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"मृतक के पिता का पूरा नाम Full name of deceased's father","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Particulars regarding the other Policies on the life of deceased","fields":[{"help":"list other policy numbers if any","type":"text","label":"पॉलिसी सं. Policy No.","options":[],"required":false,"pdf_field":""},{"help":"sum assured under other policies","type":"amount","label":"बीमा राशि Sum Assured","options":[],"required":false,"pdf_field":""},{"help":"issuing office of other policies","type":"text","label":"जारी करने वाले कार्यालय का नाम Name of issuing Office","options":[],"required":false,"pdf_field":""},{"help":"start date of other policies","type":"date","label":"आरंभ की तिथि Date of Commencement","options":[],"required":false,"pdf_field":""},{"help":"indicate if double accident benefit applies","type":"yes-no","label":"दोहरी अपघात लाभ के लिये है क्या ? Whether with Double Accident Benefits","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration and Signature","fields":[{"help":"place of declaration","type":"text","label":"स्थान Declared at","options":[],"required":true,"pdf_field":""},{"help":"date of declaration","type":"date","label":"दिनांक Date","options":[],"required":true,"pdf_field":""},{"help":"sign or affix thumb impression","type":"signature","label":"दावेदार के हस्ताक्षर / अंगूठे के निशान Signature / Thumb impression of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"signature of witness","type":"signature","label":"साक्षी के हस्ताक्षर Signature of Witness","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant and witness"},{"title":"Witness Countersignature Declaration (if declarant signs in vernacular or thumb impression)","fields":[{"help":"witness signature for vernacular/thumb impression declaration","type":"signature","label":"हस्ताक्षर Signature","options":[],"required":true,"pdf_field":""},{"help":"witness full name","type":"text","label":"पूरा नाम Full Name","options":[],"required":true,"pdf_field":""},{"help":"witness designation","type":"text","label":"पद Designation","options":[],"required":true,"pdf_field":""},{"help":"witness address","type":"text","label":"पता Address","options":[],"required":true,"pdf_field":""},{"help":"witness telephone number","type":"phone","label":"दूरभाष Tel. No.","options":[],"required":false,"pdf_field":""}],"filled_by":"witness"}],"deadlines":[],"applies_to":"Claims beyond 3 years from date of risk / revival","attachments":[],"declarations":["The claimant declares that all answers given are true in every respect.","The claimant authorizes any physician or hospital who attended the deceased to disclose health information to the Corporation and its legal advisors.","If the declarant signs in vernacular or affixes thumb impression, the witness must sign a declaration confirming the form was explained and understood."],"dropped_labels":4},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/lic/2281-claimant-s-statement"}