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DRESS OF THE BANK : 4. FULL NAME OF THE DECEASED MEMBER : 5. DATE OF ENTRY INTO SCHEME BY MEMBER Insurance Company ID ---- : 6. DATE OF DEATH OF MEMBER : : 7. WHETHER DEATH IS DUE TO ACCIDENT : YES / NO, If Yes, submit documentary proof 8. NAME OF NOMINEE * : We hereby declare that the answers to all the above questions are true in every respect. We enclose Death Certificate as the proof of death of the Member. *In case the Nominee is a minor, the guardian may fill in the claim form.

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