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PENSION AND GROUP SCHEMES UNIT ANNEXURE A GROUP INSURANCE SCHEME UNDER JANASHREE BIMA YOJANA M. P. NO. GI/ JBY/ CLAIM FORM PART A To be completed by the beneficiary Name and Address of the deceased Member Membership No* Date of Entry into the Scheme Name of Father/ Husband a Date of death b Age at death Place of death Cause of death Name of Nominee Full address of nominee Relationship with member A/c* No* I hereby declare that the answers to all the above questions are true in every respect. Witness Name Place Date Signature Signature of beneficiary Address Certified that the replies to the above questions are correct in every respect. Nominee named above is registered in the Register of Nominations at Sr. No*. Nodal Agency. SEAL PART C DISCHARGE RECEIPT a sum of Rs. Rupees. in full and final satisfaction and discharge of all our claims under the above master policy on the life of member Dated at this day of 20. GI/ JBY/ CLAIM FORM PART A To be completed by the beneficiary Name and Address of the deceased Member Membership No* Date of Entry into the Scheme Name of Father/ Husband a Date of death b Age at death Place of death Cause of death Name of Nominee Full address of nominee Relationship with member A/c* No* I hereby declare that the answers to all the above questions are true in every respect. Witness Name Place Date Signature Signature of beneficiary Address Certified that the replies to the above questions are correct in every respect. Witness Name Place Date Signature Signature of beneficiary Address Certified that the replies to the above questions are correct in every respect. Nominee named above is registered in the Register of Nominations at Sr. No*. Nodal Agency. SEAL PART C DISCHARGE RECEIPT a sum of Rs. Nominee named above is registered in the Register of Nominations at Sr. No*. Nodal Agency. SEAL PART C DISCHARGE RECEIPT a sum of Rs. Rupees. in full and final satisfaction and discharge of all our claims under the above master policy on the life of member Dated at this day of 20. GI/ JBY/ CLAIM FORM PART A To be completed by the beneficiary Name and Address of the deceased Member Membership No* Date of Entry into the Scheme Name of Father/ Husband a Date of death b Age at death Place of death Cause of death Name of Nominee Full address of nominee Relationship with member A/c* No* I hereby declare that the answers to all the above questions are true in every respect. Witness Name Place Date Signature Signature of beneficiary Address Certified that the replies to the above questions are correct in every respect. Nominee named above is registered in the Register of Nominations at Sr. No*. Nodal Agency. SEAL PART C DISCHARGE RECEIPT a sum of Rs. Witness Name Place Date Signature Signature of beneficiary Address Certified that the replies to the above questions are correct in every respect. Nominee named above is registered in the Register of Nominations at Sr. No*. Nodal Agency. SEAL PART C DISCHARGE RECEIPT a sum of Rs. Rupees. in full and final satisfaction and discharge of all our claims under the above master policy on the life of member Dated at this day of 20.

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Keywords relevant to Janshree Bima Yojana Form

  • Rupees
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  • Schemes
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