{"id":2290,"title":"FORM FOR PAYMENT OF LEAVE ENCASHMENT","purpose":"claim","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/gles-claim-form","sha256":"23fbfdc161e2b4352b1da8037b77309579982e0f1439f1db16c368bb01ae48de","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by employees or their nominees to claim payment of leave encashment benefits after leaving the organization or in case of death.","notes":["Please affix a Re.1/- Revenue Stamp on the form.","Attach original death certificate or extract if claiming due to death."],"title":"FORM FOR PAYMENT OF LEAVE ENCASHMENT","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Employee and Scheme Details","fields":[{"help":"","type":"text","label":"Master Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Scheme","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"LIC identification number of the employee","type":"text","label":"LIC ID No","options":[],"required":null,"pdf_field":""},{"help":"Employee number as per organization records","type":"text","label":"Employee No","options":[],"required":null,"pdf_field":""},{"help":"Date of birth of the employee","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Date when the employee was appointed","type":"date","label":"Date of Appointment","options":[],"required":null,"pdf_field":""},{"help":"Date when the employee left the organization","type":"date","label":"Date of Exit","options":[],"required":null,"pdf_field":""},{"help":"Cause of death if applicable","type":"text","label":"b) In case of Death Cause of Death","options":[],"required":null,"pdf_field":""},{"help":"Enter the salary amount used for calculating leave encashment","type":"amount","label":"Salary for the purpose of encashment","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or authorized signatory"},{"title":"Declaration and Signature","fields":[{"help":"Place where the form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing the form","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of the authorized person submitting the claim","type":"signature","label":"Signature of the Authorised Signatory","options":[],"required":true,"pdf_field":""},{"help":"Official seal of the organization","type":"attachment","label":"Seal","options":[],"required":null,"pdf_field":""}],"filled_by":"authorized signatory"},{"title":"Form of Discharge for Payment of Benefits in One Lump Sum","fields":[{"help":"Enter the master policy number","type":"text","label":"Master Policy No","options":[],"required":null,"pdf_field":""},{"help":"LIC identification number of the member","type":"text","label":"LIC ID","options":[],"required":null,"pdf_field":""},{"help":"Name of the member","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Employee number","type":"text","label":"Employee Number","options":[],"required":null,"pdf_field":""},{"help":"Date when the member exited","type":"date","label":"Date of Exit","options":[],"required":null,"pdf_field":""},{"help":"Select the mode of exit","type":"choice","label":"Mode of Exit (Death/ Maturity/ Resignation)","options":["Death","Maturity","Resignation"],"required":null,"pdf_field":""},{"help":"Claim amount in rupees","type":"amount","label":"Claim amount Rs.","options":[],"required":null,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Witness Signature","options":[],"required":null,"pdf_field":""},{"help":"Signature and seal of the Master Policy Holder","type":"signature","label":"Signature of the MPH (With Seal)","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or nominee"}],"deadlines":[],"applies_to":"leave encashment claims under the Master Policy","attachments":["Original Death Certificate or Extract (if applicable)","Re.1/- Revenue Stamp affixed on the form"],"declarations":["The answers to all the questions are true in every respect.","Receipt of the sum is in full satisfaction and discharge of all claims and demands under the Master Policy."],"dropped_labels":13},"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/2290-form-for-payment-of-leave-encashment"}