{"id":2285,"title":"CLAIM FORM 'A' (Form No. 3783 Rev.)","purpose":"claim","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/form-no-3783-claim-form_a","sha256":"592831cfb56169e32f24744354e988398f458a05e05961d513f7a36e80edcec5","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is for making a death claim under a life insurance policy and is to be filled by the person legally entitled to the policy money (claimant).","notes":["All answers must be given clearly in words; pen strokes, dots or dashes are not accepted.","The form must be completed before an authorized witness such as an Advocate, Corporation Agent (member of Divisional Manager's Club or above), Bank Manager, Block Development Officer, Commissioner of Oaths, Doctor, Gazetted Officer, Head Master of High School, Head Post Master or Department Sub-Post Master (not Branch Post Master), Magistrate, Officer or Development Officer with at least 5 years standing, or President of Village Panchayat or Local Board.","If the declarant signs in a local language or affixes thumb impression, the witness must sign the additional declaration.","In case of dispute in interpretation, the English version of the form shall prevail."],"title":"CLAIM FORM 'A' (Form No. 3783 Rev.)","submit":{"to":"servicing Branch of the Life Insurance Corporation of India","how":"","address":""},"purpose":"claim","sections":[{"title":"Claimant's Statement","fields":[{"help":"Enter the full name of the claimant legally entitled to the policy money","type":"text","label":"Name of the Claimant","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's age in years","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's telephone number","type":"phone","label":"Tel. No.","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's full postal address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Specify your relationship to the deceased insured person","type":"text","label":"Relationship to the deceased life assured","options":[],"required":null,"pdf_field":""},{"help":"Select the legal capacity under which you claim the policy money","type":"choice","label":"Nature of Title under which the claim for policy money is submitted viz : Nominee, Assignee, Executor, Administrator, Trustee of Beneficiary","options":["Nominee","Assignee","Executor","Administrator","Trustee","Beneficiary"],"required":null,"pdf_field":""},{"help":"Enter the policy number under which claim is made","type":"text","label":"In Connection with claim under policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the sum assured amount of the policy","type":"amount","label":"for Rs.","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the deceased life assured","type":"text","label":"on the life of (Insert full name of the deceased)","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Particulars regarding the deceased life assured","fields":[{"help":"Enter full name of the deceased","type":"text","label":"Shri/Smt.","options":[],"required":null,"pdf_field":""},{"help":"Enter the place where the deceased died","type":"text","label":"Place of death of the life assured","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of death of the deceased","type":"date","label":"Date of death","options":[],"required":null,"pdf_field":""},{"help":"Enter exact time of death with AM or PM","type":"text","label":"Exact time of death AM/PM","options":[],"required":null,"pdf_field":""},{"help":"Enter age of deceased at time of death","type":"number","label":"Age of life assured at death","options":[],"required":null,"pdf_field":""},{"help":"Enter duration of the last illness suffered by the deceased","type":"text","label":"Duration of last illness","options":[],"required":null,"pdf_field":""},{"help":"Enter the immediate cause of death","type":"text","label":"Immediate cause of death","options":[],"required":null,"pdf_field":""},{"help":"Enter the last occupation of the deceased","type":"text","label":"Last occupation of the life assured","options":[],"required":null,"pdf_field":""},{"help":"Enter the last known address of the deceased","type":"text","label":"Last address of the life assured","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the deceased's father","type":"text","label":"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":"Enter policy number of other policies on deceased's life","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter sum assured under other policies","type":"amount","label":"Sum Assured","options":[],"required":null,"pdf_field":""},{"help":"Enter name of office and branch issuing the other policies","type":"text","label":"Name of issuing Office & Servicing Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter date of commencement of other policies","type":"date","label":"Date of Commencement","options":[],"required":null,"pdf_field":""},{"help":"Indicate if other policies include double accident or extended disability benefits","type":"yes-no","label":"Whether with Double Accident or Extended Disability Benefits","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Medical History","fields":[{"help":"Enter date or approximate time when deceased first complained of illness","type":"text","label":"When did the deceased first complain of being not in usual good health?","options":[],"required":null,"pdf_field":""},{"help":"Describe the illness complained of at that time","type":"text","label":"Nature of illness then complained","options":[],"required":null,"pdf_field":""},{"help":"Enter names of doctors who treated the deceased during last illness","type":"text","label":"The names of medical attendants during the last illness","options":[],"required":null,"pdf_field":""},{"help":"Provide a table with columns: Date(s) of consultation, Name and address of Doctor or Hospital, Nature of complaint","type":"table","label":"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","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration and Authorization","fields":[{"help":"Sign or affix thumb impression here","type":"signature","label":"Signature / Thumb impression of the claimant","options":[],"required":true,"pdf_field":""},{"help":"Print full name of claimant","type":"text","label":"Full Name","options":[],"required":true,"pdf_field":""},{"help":"Enter place where form is signed","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Witness must sign here","type":"signature","label":"Signature of Witness","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Certification by Witness","fields":[{"help":"Witness must sign here certifying the form was explained to declarant","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of witness certifying the explanation","type":"text","label":"Full Name","options":[],"required":true,"pdf_field":""},{"help":"Enter designation of witness certifying the explanation","type":"text","label":"Designation","options":[],"required":true,"pdf_field":""},{"help":"Enter address of witness certifying the explanation","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter telephone number of witness certifying the explanation","type":"phone","label":"Tel. No.","options":[],"required":null,"pdf_field":""}],"filled_by":"witness"}],"deadlines":[],"applies_to":"death claims under life insurance policies","attachments":["Certified extract from death register","The original policy document with Deed/s of assignment/s, if any"],"declarations":["The claimant declares that all statements made in the form are true in every respect.","The claimant authorizes any physician or hospital who attended or examined the deceased to disclose any information regarding the deceased's health to the Corporation or its legal advisors.","If the declarant signs in vernacular or affixes thumb impression, the witness must also sign a declaration certifying the form was explained to the declarant in their language."],"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/2285-claim-form-a-form-no-3783-rev"}