{"id":2294,"title":"GSLI CLAIM FORM","purpose":"claim","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/gsli-claim-form","sha256":"bc1ea5c4d50bb5a6601062d34bc000f691f4f328435beea6a7dc22dafffd5a16","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for the Master Policyholder to submit a claim under the Group Savings Linked Insurance Scheme for an employee who has exited the service.","notes":["Attach original death certificate in case of death.","If death is due to accident and policy is covered under DAB, attach attested copies of FIR, Post Mortem Report, and Police Inquest Report.","Form to be completed by the Master Policyholder."],"title":"GSLI CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Employee and Policy Details","fields":[{"help":"","type":"text","label":"Name of the Institution","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Master Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured Member","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"LICID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Employee No.","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Joining service","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Joining the Scheme","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date last attended duties","options":[],"required":null,"pdf_field":""},{"help":"Describe any category or amount changes since joining","type":"text","label":"Category and amount change since joining the scheme","options":[],"required":null,"pdf_field":""},{"help":"Enter last drawn salary or last category","type":"text","label":"Last drawn salary/last category","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Due Date for payment of the First Contribution(DD/MM/YYYY)","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Exit from the Scheme.","options":[],"required":null,"pdf_field":""},{"help":"Specify the mode of exit","type":"text","label":"Mode of Exit(Death, Retirement, Resignation, Termination etc.,)","options":["Death","Retirement","Resignation","Termination","Other"],"required":null,"pdf_field":""},{"help":"Describe cause of death and attach original death certificate","type":"text","label":"In case of death, Cause of Death (please enclose Original Death Certificate)","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Due Date for payment of the last contribution(DD/MM/YYYY)","options":[],"required":null,"pdf_field":""}],"filled_by":"Master Policyholder"},{"title":"Contribution Details and Declarations","fields":[{"help":"Enter the amount of last monthly contribution recovered","type":"amount","label":"Last Monthly contribution recovered from the Insured Member","options":[],"required":null,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"The Date on which the last contribution was paid to the Corporation.","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Was the employee in the service of the employer on the date of death","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if any contributions remain unpaid","type":"text","label":"Whether any contributions remain unpaid during Membership. (If so, give details)","options":[],"required":null,"pdf_field":""},{"help":"Signature of the witness","type":"signature","label":"Witness Signature","options":[],"required":null,"pdf_field":""},{"help":"Signature of the Master Policyholder","type":"signature","label":"Signature of the Master Policyholder","options":[],"required":null,"pdf_field":""}],"filled_by":"Master Policyholder"}],"deadlines":[],"applies_to":"Group Savings Linked Insurance Scheme policy claims","attachments":["Original Death Certificate","Copy of First Information Report (if death due to Accident and policy covered under DAB)","Copy of Post Mortem Report (if death due to Accident and policy covered under DAB)","Copy of Police Inquest Report (if death due to Accident and policy covered under DAB)"],"declarations":["The particulars given are true and correct.","The member has been insured under the scheme on the date of exit.","All premiums have been paid to the Corporation on behalf of the member."],"dropped_labels":2},"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/2294-gsli-claim-form"}