LIFE Insurance Corporation OF India PDF

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Form No 357

LIFE INSURANCE CORPORATION OF INDIA BRANCH OFFICE : KABABURGI CB - II AFFIDAVIT IN LIEU OF CLAIM FROM B, B1 I Smt. SHIVALEELA wife of NAVAGONDA PATIL aged about 47 years, occupation: FDA H.K.E.Socity ITI Kalaburgi Residing at Kalaburgi do herby solemnly affirm and state an oath as follows:

1. That policy of life insurance bearing no 666471808 was issued by the life insurance corporation of India Kalaburgi CB II Branch office, on the life of Smt. GANGAMMA Wife of BASAWARAJ Age 44 working as Agriculture. 2. That the said life assured died at Malkhed Sedam on 26-02-2018 at 3:30pm.

3. That I am well acquainted with the deceased life assured stated above during her life time and that I am disinterested person in claim amount under the aforesaid policy. I am also not related to the above stated deceased person. 4. That I have not given any declaration so for to the life insurance corporation of India in respect of the claim under the aforesaid policy either in the forms supplied by the life insurance corporation of India or any other them.

5. That the cause of the death of aforesaid assured was Paralysis and that the last medical attendants certificate in claim form ‘B’ could not be got completed due to following reason After Paralysis Stroke Died Within One Hour at Residence. 6. That I was not present at the time of the death of the life assured. I saw the dead body of the life assured at the time of disposal of the body.

That the contents of this affidavit are true to the best of my knowledge and belief. Dated at Kalaburgi this 11th day of December-2019

(Signature of declarant)...