{"id":2302,"title":"Annexure VII","purpose":"claim","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/annexure-vii","sha256":"6e7defb4f8e9d69ed557e25840d417f680aa72e5e9bd05e790f62ae8a76c0ed0","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used to provide a credit account statement and related declarations for claims under schemes involving Lender Borrower Groups. It is filled by the Master Policy Holder and the beneficiary.","notes":["This form is to be used only in cases of schemes involving Lender Borrower Groups.","Attach a copy of cancelled cheque with nominee details.","Signatures and seals are required in multiple parts of the form."],"title":"Annexure VII","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"PART- A - CREDIT ACCOUNT STATEMENT","fields":[{"help":"","type":"text","label":"Name of the Group Master Policy Holder","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Group Master Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured Member","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"LIC identification number of the insured member","type":"text","label":"LIC ID","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Commencement of Risk","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Death","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Indian Rupees","type":"amount","label":"Sum Assured for which the Member was Insured","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Indian Rupees","type":"amount","label":"Original Loan Amount","options":[],"required":null,"pdf_field":""},{"help":"Enter amount recovered towards loan in Indian Rupees","type":"amount","label":"Particulars/Amount of recoveries made by the Master Policy Holder towards Loan","options":[],"required":null,"pdf_field":""},{"help":"Calculate as Original Loan Amount minus recoveries","type":"amount","label":"Outstanding Loan – Balance as on the date of death (9 – 10)","options":[],"required":null,"pdf_field":""},{"help":"Calculate as Sum Assured minus Outstanding Loan","type":"amount","label":"Balance Loan Amount – Claim payable to the Master Policy Holder (8 minus11)","options":[],"required":null,"pdf_field":""},{"help":"Calculate as Sum Assured minus Balance Loan Amount","type":"amount","label":"Balance Claim Amount payable to the beneficiary of the insured member (8 minus 12)","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Authorized signatory signs here","type":"signature","label":"Signature of the Authorized Signatory of MPH","options":[],"required":null,"pdf_field":""},{"help":"Affix seal of Master Policy Holder","type":"attachment","label":"Seal of MPH","options":[],"required":null,"pdf_field":""}],"filled_by":"Master Policy Holder"},{"title":"PART - B - DISCHARGE RECEIPT FOR PAYMENT UNDER ELIGIBLE LENDER BORROWER SCHEME","fields":[{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the insured member","options":[],"required":null,"pdf_field":""},{"help":"Write full name","type":"text","label":"Name of the Master policy Holder","options":[],"required":null,"pdf_field":""},{"help":"Write full name","type":"text","label":"Name of the beneficiary","options":[],"required":null,"pdf_field":""},{"help":"Enter membership or LIC ID","type":"text","label":"Membership No / LIC id","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Indian Rupees","type":"amount","label":"Amount payable to the Master Policy Holder","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Indian Rupees","type":"amount","label":"Amount payable to the Beneficiary","options":[],"required":null,"pdf_field":""},{"help":"Signatures of nominee/claimant and MPH with seal","type":"signature","label":"Signature of the Nominee* /Claimant & Signature of MPH with office seal","options":[],"required":null,"pdf_field":""}],"filled_by":"Master Policy Holder and Beneficiary"},{"title":"PART - C - Details of nominee","fields":[{"help":"Full name of nominee","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-mail Id","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No.","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":null,"pdf_field":""},{"help":"Enter branch name","type":"text","label":"Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter full branch address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of the bank branch","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"Attach a copy of cancelled cheque","type":"attachment","label":"Copy of cancelled cheque to be attached","options":[],"required":null,"pdf_field":""}],"filled_by":"Nominee or claimant"},{"title":"PART - D - Certification","fields":[{"help":"Authorized signatory signs here","type":"signature","label":"Signature of Master Policy Holder","options":[],"required":null,"pdf_field":""},{"help":"Enter registration number","type":"text","label":"Registration Number","options":[],"required":null,"pdf_field":""},{"help":"Affix seal of Master Policy Holder","type":"attachment","label":"Seal","options":[],"required":null,"pdf_field":""},{"help":"Affix revenue stamp","type":"attachment","label":"Revenue Stamp","options":[],"required":null,"pdf_field":""}],"filled_by":"Master Policy Holder"}],"deadlines":[],"applies_to":"schemes involving Lender Borrower Groups","attachments":["Copy of cancelled cheque","Seal of MPH","Revenue Stamp"],"declarations":["The information/details furnished in the Credit Account Statement are verified for accuracy and true in every respect.","Authorization from the insured member for making payment to the Master Policy Holder to the extent of outstanding loan is obtained.","The Master Policy Holder authorizes payment as stated in field 13 directly to the registered Nominee.","The information/details furnished in the credit account statement in Part-A are correct and as available in the books."],"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/2302-annexure-vii"}