{"id":2289,"title":"DISCHARGE OF -","purpose":"claim","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/form_no_5180-1-","sha256":"009939f32254f19ae1ac7b0007aa2c6a5404a9b3eecee63bc0c923ea8e62c15e","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is used by the proposer or life assured to claim survival benefit or maturity proceeds under various LIC policies and to acknowledge receipt of the payment. The policyholder or claimant fills it.","notes":["Strike out which deductions are not applicable.","Payment will be made by non-negotiable account payee cheque unless consent for demand draft/money order is given.","Use block letters where applicable.","In case of dispute, the English version of the form shall prevail.","The discharge form must be signed and witnessed properly to be valid."],"title":"DISCHARGE OF -","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy and Payment Details","fields":[{"help":"Enter the name of the life assured as per the policy.","type":"text","label":"on the life of","options":[],"required":null,"pdf_field":""},{"help":"Enter the amount received in rupees.","type":"amount","label":"Rupees","options":[],"required":true,"pdf_field":""},{"help":"Enter the due date of payment under the Children's Deferred Assurance Policy.","type":"date","label":"Cash Option which fell due for payment on","options":[],"required":null,"pdf_field":""},{"help":"Enter the maturity date under the Guaranteed Triple Benefit Policy.","type":"date","label":"Sum Assured which fell due for payment on the date of maturity, viz","options":[],"required":null,"pdf_field":""},{"help":"Enter the due date of anticipated instalment under the relevant policies.","type":"date","label":"Anticipated instalment which fell due for payment on","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer / life assured"},{"title":"Payment Calculation","fields":[{"help":"Enter the gross amount payable.","type":"amount","label":"देय राशि/देय राशि Amount Payable रु. Rs.","options":[],"required":true,"pdf_field":""},{"help":"Enter any unpaid premiums to be deducted.","type":"amount","label":"वजा/घटायें/Less न भरलेले हप्ते / अदत्त प्रीमियम Unpaid Premium रु. Rs.","options":[],"required":null,"pdf_field":""},{"help":"Enter interest on premium if applicable.","type":"amount","label":"हप्त्यावरील व्याज / प्रीमियम पर ब्याज Interest on Premium रु. Rs.","options":[],"required":null,"pdf_field":""},{"help":"Enter any policy loan amount to be deducted.","type":"amount","label":"पॉलिसीवरील कर्ज/पॉलिसी ऋण Policy Loan रु. Rs.","options":[],"required":null,"pdf_field":""},{"help":"Enter interest on policy loan if applicable.","type":"amount","label":"त्यावरील व्याज / ऋण पर ब्याज Interest thereon रु. Rs.","options":[],"required":null,"pdf_field":""},{"help":"Enter any other deductions applicable.","type":"amount","label":"अन्य कपाती / अन्य कटौतियाँ Other deductions रु. Rs.","options":[],"required":null,"pdf_field":""},{"help":"Enter the net amount payable after deductions.","type":"amount","label":"निव्वळ देय रक्कम/शुद्ध देय राशि Net amount payable रु. Rs.","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer / life assured"},{"title":"Declarations and Signatures","fields":[{"help":"Enter the date of signing.","type":"date","label":"दिनांक this","options":[],"required":true,"pdf_field":""},{"help":"Enter the month and year of signing.","type":"text","label":"महिना/माह day of 20","options":[],"required":true,"pdf_field":""},{"help":"Enter the place where the form is signed.","type":"text","label":"ठिकाण/दिनांकित स्थान Dated at","options":[],"required":true,"pdf_field":""},{"help":"Signature of the proposer or life assured.","type":"signature","label":"Signed by Shri/Smt.","options":[],"required":true,"pdf_field":""},{"help":"Signature of the witness who knows the life assured and can attest the signature in English.","type":"signature","label":"साक्षीदार स्वाक्षरी / साक्षी हस्ताक्षर / Signature :","options":[],"required":true,"pdf_field":""},{"help":"Full name of the witness.","type":"text","label":"पूर्ण नाव / पूरा नाम / Full Name :","options":[],"required":true,"pdf_field":""},{"help":"Designation of the witness if applicable.","type":"text","label":"पद / पद / Designation :","options":[],"required":null,"pdf_field":""},{"help":"Address of the witness.","type":"text","label":"पत्ता/ पता / Address :","options":[],"required":null,"pdf_field":""},{"help":"Signature and address where the cheque should be sent.","type":"text","label":"Signature in full / short in English / in Vernacular Present address on which cheque is to be sent","options":[],"required":true,"pdf_field":""},{"help":"Affix a Re. 1 revenue stamp on the form.","type":"attachment","label":"1 रु. चा रेव्हेन्यू स्टॅम्प / 1 रु. का राजस्व टिकट / Re. 1 Revenue Stamp","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer / life assured and witness"},{"title":"Consent for Payment by Demand Draft / Money Order","fields":[{"help":"Name of the bank where demand draft or money order is to be drawn.","type":"text","label":"Bank","options":[],"required":null,"pdf_field":""},{"help":"Place where the request is made.","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of the request.","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature(s) of the claimant(s) requesting payment by demand draft or money order.","type":"signature","label":"Signature/s of the Assured/claimants/s","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer / life assured"},{"title":"Attestation for Illiterate Person","fields":[{"help":"Signature of the official attesting the thumb impression.","type":"signature","label":"Signature of the attesting official","options":[],"required":true,"pdf_field":""},{"help":"Official seal of the attesting office.","type":"attachment","label":"seal of the Office","options":[],"required":true,"pdf_field":""}],"filled_by":"attesting official"}],"deadlines":[],"applies_to":"Cash option under Children's Deferred Assurance Policy, Maturity proceeds under Triple Benefit Policy, Anticipated instalment under Anticipated Endowment Policy, Money Back Policy, Cash & Cover Policy, Anticipated Whole Life Policy, Jeevan Surabhi, Jeevan Sanchay, Jeevan Sneha, Jeevan Akshay, and Return of 50% Premiums under Children's Anticipated Policy.","attachments":["Re. 1 Revenue Stamp"],"declarations":["I acknowledge receipt of the payment in full satisfaction of all claims under the policy.","I declare that no notice of assignment or reassignment has been served to LIC except those registered.","I have not dealt with the policy in any other way.","This discharge must be signed by the proposer/life assured and witnessed by an English knowing person who knows the life assured.","Signature in Indian languages must have English translation written beneath.","Illiterate persons must have their thumb impression attested by authorized officials as specified.","Payment by demand draft or money order is at the risk and responsibility of the payee and bank charges will be deducted from policy monies."],"dropped_labels":3},"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/2289-discharge-of"}