{"id":2295,"title":"Claim Form for Employer-Employee Group Insurance Scheme","purpose":"claim","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/annexure-ii-2","sha256":"6d4a9c5b85093c307c4906d42465862ea3d7de90e78e4b3b2e1345db1ea2a008","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is for the master policyholder of the Group Insurance scheme to claim insurance benefits for a deceased member under the employer-employee group insurance scheme.","notes":["Affix Re 1 revenue stamp on the discharge receipt.","The form is to be completed by the master policyholder of the Group Insurance scheme."],"title":"Claim Form for Employer-Employee Group Insurance Scheme","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Member and Scheme Details","fields":[{"help":"","type":"text","label":"Name of the scheme","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Master Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Full Address of the Master Policy holder","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Full Name of the deceased Member","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"LIC id","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Employee No","options":[],"required":null,"pdf_field":""},{"help":"Format: date","type":"date","label":"Date of appointment","options":[],"required":null,"pdf_field":""},{"help":"Format: date","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Format: date","type":"date","label":"Date of entry into scheme","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Category","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Salary","options":[],"required":null,"pdf_field":""},{"help":"Format: date","type":"date","label":"Date of death of the Member","options":[],"required":null,"pdf_field":""},{"help":"Format: time","type":"text","label":"Time of Death","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Cause of death","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place of death","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Amount of Sum assured","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the Member in the service of the employer on the date of death ?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Format: date","type":"date","label":"Last premium paid on","options":[],"required":null,"pdf_field":""},{"help":"Period for which premium was due","type":"text","label":"For Due","options":[],"required":null,"pdf_field":""},{"help":"M=Monthly, Q=Quarterly, H=Half-yearly, Y=Yearly","type":"choice","label":"Mode of payment","options":["M","Q","H","Y"],"required":null,"pdf_field":""},{"help":"Format: date","type":"date","label":"Date when the member last attended duty","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Was the member absent from duty on grounds of ill health on date of entry in the scheme?","options":["YES","NO"],"required":null,"pdf_field":""}],"filled_by":"master policyholder"},{"title":"Record of Absence from Duty","fields":[{"help":"Columns: Period From, Period To, Nature of Leave, Reason as stated in Application Form, Date of resumption of duty after leave","type":"table","label":"Please give below the record of absence from duty by the member during last three years prior to death","options":[],"required":null,"pdf_field":""}],"filled_by":"master policyholder"},{"title":"Declaration and Signature","fields":[{"help":"","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Format: date","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign with official seal","type":"signature","label":"Signature of Master Policy Holder","options":[],"required":null,"pdf_field":""}],"filled_by":"master policyholder"},{"title":"Discharge Receipt","fields":[{"help":"","type":"text","label":"Master Policy No","options":[],"required":null,"pdf_field":""},{"help":"Amount received in Rupees","type":"amount","label":"Received a sum of Rs","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Format: date","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign with official seal","type":"signature","label":"Signature of Master Policy Holder","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of witness","options":[],"required":null,"pdf_field":""}],"filled_by":"master policyholder"}],"deadlines":[],"applies_to":"Employer-Employee Group Insurance Scheme claims","attachments":[],"declarations":["The answers to all the above questions are true in every respect.","The above employee was a member of the group insurance scheme and was in our service on the date of death.","Upon payment, the Corporation will be discharged of our entire claim in respect of the above insured member."],"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/2295-claim-form-for-employer-employee-group-insurance-scheme"}