PLI/ RPLI SERVICE REQUESTS

SN0 Request Type Documents to be submitted Application

form
1 Maturity  Application form
 Original Policy Document/Indemnity Bond
 Premium Receipt Book/Pay Recovery FORM
2 Survival Benefit certificate(last 6 months)
(Page No.4,5)
 Self Attested copy of ID and Address Proof
 Self Attested copy of POSB passbook
 Loan Receipt Book (In case of loan availed)
Surrender  Surrender Application form
(Active/Inactive  Original Policy Document/Indemnity Bond FORM
policies)  Premium Receipt Book/Pay Recovery
certificate(last 6 months) (Page No.6)
 Self Attested copy of ID and Address Proof
 Self Attested copy of POSB passbook
 Loan Receipt Book (In case of loan availed)
3 Surrender  Surrender Application form
(Lapsed Policies)  Reduced Paid Up Application form FORM
 Original Policy Document/Indemnity Bond
 Premium Receipt Book/Pay Recovery (Page No.7)
certificate(last 6 months)
 Self Attested copy of ID and Address Proof
 Self Attested copy of POSB passbook
 Loan Receipt Book (In case of loan availed)
4 Loan  Application form
 Self attested copy of Original Policy Document FORM
 Premium Receipt Book/Pay Recovery
certificate(last 6 months) (Page No.8,9)
 Self Attested copy of ID and Address Proof
 Self Attested copy of POSB passbook
 Loan Receipt Book (In case of loan availed)
 Self Attested copy of Identity & Address Proof of
Witness
5 Revival  Application form with Medical Certificate
FORM
 Premium Receipt Book/Pay Recovery certificate
upto the last pay drawn (Page No.10,11)
6 Fresh Premium  Application form FORM
receipt Book  Old/Used Up Premium receipt book (Page No.12)
7 Duplicate Premium  Application form
receipt Book  Receipt for Duplicate PRB Fee Rs.20/- McCamish FORM

(Page No.13)
8 Duplicate Policy  Insurant’s request letter
Document  Receipt for Duplicate Bond Fee Rs.100/- paid in
FORM
(Active/Lapsed McCamish
Policies)  Indemnity Bond on Rs.50/- Non Judicial Stamp (PageNo.14, 15)
Paper + Self Attested copy of ID/Address Proof
Duplicate Policy  Insurant’s request letter FORM
Document (Matured  Indemnity Bond on Rs.200/- Non Judicial Stamp
(Page No.16,17)
Policies) Paper + Self Attested copy of ID/Address Proof
9 Billing Method  Application form
FORM
Change  Original Policy Document
(Cash to Pay  Premium Receipt Book/Pay Recovery (Page No.18)
Recovery /Pay certificate(last 6 months)
Recovery to Cash)  Self Attested copy of ID/Address Proof
10 Billing Frequency  Application form
FORM
Change(Monthly to  Original Policy Document
Yearly/Quarterly/  Premium Receipt Book (Page No.19)
Half Yearly)  Self Attested copy of ID/Address Proof
11 Address Change  Application form
FORM
 Original Policy Document
Premium Receipt Book (Page No.20)
 Self Attested copy of ID/Address Proof
12 Name Change  Application form
 Original Policy Document FORM
 Premium Receipt Book (Page No.21)
 Self Attested copy of Gazette Notification
 Self Attested copy of Identity Proof
13 Nomination change  Application form
FORM
 Original Policy Document
 Self Attested copy of Identity Proof of Insurant (Page No.22,23)
 Self Attested copy of Identity Proof of Nominee
14 Conversion  Application form FORM
(WLA---- EA)  Original Policy Document WLA-EA(Page-24)
(CWLA - EA)  Premium Receipt Book FORM
Alteration in  Medical certificate in case of increase in Maturity
CWLA-EA(Page -25)
Maturity Age) Age FORM
 Self Attested copy of Identity Proof (Altrn-Page-26)
15 Commutation  Application form
(Reduction in  Original Policy Document FORM
Premium or Sum  Premium Receipt Book (Page No.27)
Assured)  Self Attested copy of Identity Proof
16 Mobile Number/  Application form FORM
Email ID Updation
(Page No.28)
17 Income Tax  Application form FORM
Statement (Page-29)
SN Request Type Documents to be submitted Appln form
Natural Death – All deaths except Death due to suicide,
murder or accident
 Application form
 Original Policy Document/Indemnity Bond FORM
 Premium Receipt Book/Pay Recovery certificate(last 6 (Page No. 30,
months) 31,32)
 Self Attested copy of Death Certificate
 Cause of Death issued by Village Panchayat/ Medical FORM
Practitioner or Certificate from Doctor who last attended Indemnity
the Insurant clearly mentioning reason of death/Death Bond
Summary) (Page No. 33,
34)
 Self Attested copy of ID and Address Proof of claimant
Death Claim  Self Attested copy of POSB passbook (Claimant)
18
(With Nomination)  Loan Receipt Book (In case of loan availed)
Un-Natural Death –Death due to suicide, murder or
accident
 Application form
 Original Policy Document/Indemnity Bond
 Premium Receipt Book/Pay Recovery certificate(last 6
months) FORM
 Self Attested copy of Death Certificate
 Self-Attested copy of FIR & Postmortem report Indemnity
Bond for
 Indemnity Bond for Unnatural Death Unnatural
 Self Attested copy of ID & Address Proof of claimant Death
 Self Attested copy of POSB passbook (Claimant) (Page No.
40,41)
 Loan Receipt Book (In case of loan availed)
For Aggregate Claim amount above 3 Lakhs
 All the above mentioned documents based on the category
of death
 Self-Attested copy of Legal Documents in support of his/her
claim (Letter of Administration or Succession Certificate
or Probate of Will)
For Aggregate Claim amount upto 3 Lakhs-Waiver of
Death Claim Succession certificate by submitting below documents
(Without  Self Attested copy of Legal Heir Certificate
Nomination –No  Claim application elaborating the situation under which
he is unable to produce succession certificate. FORM
Nominee cases)
 Affidavit on Rs.10/- e-stamp paper duly signed by
claimant and attested by Notary. (Page No. 35,36
 Letter of indemnity on Rs.100/- e-stamp/Non Judicial 37,38,39)
stamp paper duly attested by Notary.
 Letter of disclaimer on affidavit Rs.10/- e-stamp/Non
Judicial stamp paper duly attested by Notary.
 Affidavit on Rs.50/- e-stamp paper duly signed by
claimant and attested by notary
Annex - II

CLAIM FORM FOR MATURITY/SURVIVAL BENEFIT OF PLI/RPLI POLICY

(Please fill in BLOCK letters)

Service Request No. :

(For Official only)
1 Policy Details :

i Policy Type: ii Policy No. :

iii Name of Insurant : iv Sum Assured :

Date of Acceptance :
v vi Premia Frequency (Monthly/Quarterly etc):
(dd/mm/yyyy)
Date of Survival Benefit Due : Date of Maturity :
vii (dd/mm/yyyyy) OR (dd/mm/yyyyy)
(AEA Policy)

viii Loan taken against policy : Yes No

Date of last Installment of Loan Repayment :

If yes, Loan Sanction Amount :
(dd/mm/yyyy)
2.
Outstanding Loan Amount :

Missing Credit Premium Details:

3.
(in case any premia paid is not included in the Intimation Letter)

4. Communication Address :

Address :

District : State :

PIN Code : Contact Phone Number :

Aadhar Number : e-Mail ID :

5. Name of Spouse (in case of Yugal Suraksha Policy):
6. Office Address of DDO (For Pay Recovery Policy only)

Name & Designation of DDO: Name of Organization:

Office Address: District & State :

PIN Code : Phone no & email id:

7. Account Details (if payment desired through NEFT/Credit)

Bank Account Details Post Office Saving Bank Account Details

Account Number: Account Number:

Account Type: Name of Account Holder

OR
Name of Account Holder: Post Office Name :

Name of Bank: CBS Post Office (Y/N):

Address or Branch Name: Pin code/SOL ID

 IFSC code: First page of Pass Book Enclosed (Y/N)

Cancelled Cheque Enclosed (Y/N):

Documents Enclosed: Yes/No/ NA(Not Applicable)

1. Original Policy Bond or Letter of Indemnity

2. Self Attested copy of ID proof of the Insurant

3. Self Attested copy of address proof of the Insurant

4. Documents of Credit /Premium Receipt Book (D.O.C. if Pay policy or Premium Receipt Book if Cash Policy and all the paid

premium not updated on McCamish Software)

5. Loan Receipt Book (if outstanding loan amount as mentioned in Intimation letter and Loan Receipt book differs)

6. Cancelled Cheque of Insurant Bank Account for Bank Mandate or self attested copy of POSB passbook

7. Self-Attested Copy of ID proof of Messenger (if messenger appointed by Insurant for submission of Maturity claim form)

8. Self-Attested Copy of Address proof of Messenger (if messenger appointed by Insurant for submission of Maturity claim form)

9. Self-Attested medical certificate of insurant from Govt. Hospital/Govt. accredited hospital

Or
self-attested copy of passport clearly showing visa details and date of departure from India In case messenger is appointed

10.

Date : ______________

Appointment of Messenger
(Required only if Maturity/Survival claim form is being submitted through Messenger)

I hereby , am unable to visit post office, being medically unfit

or outside India, for submission of Maturity/survival benefit claim form. I hereby appoint Shri/Smt./Ms.
, whose signature is given below, as a messenger for submission of my
maturity/survival benefit claim form along with necessary documents.

Signature/Thumbprint of Insurant
In case Insurant is illiterate, there should be two literate witnesses-

Witness Name & Address Signature

Witness 1
Witness 2
----------------------------------------------------------------------------------------------------------------------------------------------------------------------
For Official Use
Certified that I have checked all the documents enclosed and compared with the original documents produced by the
Insurant/messenger and verified the averments made in the Maturity claim form based on these documents and found no
discrepancies.

Date:- Signature of BPM/SPM/PM/ CPC in-Charge

Name :
Designation:
Office Stamp:
 APPLICATION FOR SURRENDER OF POSTAL/ RURAL LIFE INSURANCE POLICY
(Please fill in the columns in block letters)

1. Policy No. : ___________________________

__________________________________

2. Date of Acceptance: __________________________

3. Date of Maturity: ___________________________

____________________________

4. Sum Assured: ___________________________

_______________________________

5. Name of the Insurant: ___________________________

Address :

Pin Code

6. Details of loan taken on policy if any,

i. Sanction date- __________________

[Link] of loan- __________________

[Link] of repayment of loan- ___________________

7. Reason/Circumstances for surrendering policy _____________________________________

__________________________

8. Name of Post Office through which payment of surrender value is desired.

__________________________________________

9. For payment through Post office, please provide following information about your Post Office
account:-

Account No. : __________________________________

_____________________

Name of Post Office: ___________________________

Branch Name: _________________________________

10. For payment through cheque, kindly acknowledge the request with the signature.

PLEASE ISSUE CHEQUE for payment ________________

__________________ (SIGNATURE)

Documents Attached:
a) Policy document.
b) Loan Repayment Receipt Book if loan was taken.
c) Premium Receipt Book /Certificate
Certificate of Pay Disbursing Officer
e) Copy of Pan card / Aadhar card

Date: Signature of Insurant/

Claimant

Name:

Mobile no
 APPLICATION FOR REDUCED PAID UP OF PLI/RPLI POLICY

அ ந

ெப ந

தைலைம அ சலக அதிகாாி/

அதிகாாி அ சலக அதிகாாி,

________________________(CPC Name)

________________________

ஐயா,

என PLI/RPLI பா சி எ _________________________ பிாிமிய ெதாைக

கைடசியாக _______________________ வைர க ேள . எ னா இத ேம

இ த பா சியி பிாிமிய ெதாைக க ட இயலாத காரண தினா எ ைடய

PAIDUP ெச
பா சிைய REDUCED-PAID த ப தா ைம ட ேக ெகா கிேற .

ேம ஒ பா சிைய REDUCED-PAIDUP ெச தத பி அ த பா சியி

ேம ெகா பிாிமிய ெதாைக ெச த யா எ பைத நா அறிேவ .

இட :

ேததி: இ ஙன ,

_______________
Annex - II
APPLICATION FOR LOAN ON SECURITY OF PLI/RPLI POLICY
(Please fill in BLOCK letters)

Service Request No. :

(For Official only)
1 Policy Details (particular of policy against which the loan is desired):
Name of Insurant :
i Policy No. : ii Name of Spouse (in case of Yugal Suraksha Policy) :

Date of Acceptance :
iii Sum Assured : iv
(dd/mm/yyyy)

Date of Maturity:
v vi Amount of Loan required :
(dd/mm/yyyy)

vii Purpose for which Loan is required :

2. Details of Previous Loan taken on this Policy (if any)

i Amount of Previous Loan : ii Sanction No.:

iii Sanction Date: iv Date of final repayment of previous Loan:

3. Missing Credit Premium Details (Please enclose supporting documents)

4. Communication Address :

Address :

District : State :

PIN Code : Contact Phone Number :

Aadhar Number : e-Mail ID :

5. Office Address of DDO (For Pay Recovery Policy only)

Name & Designation of DDO : Name of Organization :

Office Address : District & State :

PIN Code : Phone No. & e-Mail ID :

6. Account Details (if payment desired through NEFT/RTGS/Other Credit)

Bank Account Details Post Office Saving Bank Account Details

Account Number: Account Number:

Account Type: Name of Account Holder

Name of Account Holder: Post Office Name :
OR
Name of Bank: CBS Post Office (Y/N):

Branch Name: Pin code/SOL ID

IFSC code:
First page of Pass Book Enclosed (Y/N)
Cancelled Cheque Enclosed (Y/N):
7. Assignment prescribed under Rule 31 of Estate Duty Rules, 1953, in respect of PLI/RPLI Policies assigned to the
President for the purpose of paying Estate Duty:
do hereby assign the benefit of all moneys to become payable under the Postal
Life Insurance Policy/Rural Postal Life Insurance Policy No assuring the sum of
` to the President of India for the purpose of paying Estate Duty in accordance with the provision
contained in clause (f) of sub section (1) of Section 33 of the Estate Duty Act, 1953, which after my death my estate may become liable to
pay to the Government of India.
Provided, however, that in the event of my surviving the date on which the said policy if so expressed would mature or the policy is
surrendered by me, the benefit of the policy and the right to receive moneys there under shall revert to me as if this assignment had not
been made. It is further agreed that if the policy matures before my death or is surrendered by me, then on my request the Insurer will
upon the delivery of the policy pay all or so much or the sum due to me as may be specified in such request, to the Government of India
-Deposits and Advances- deposits bearing interest-other Deposits
treated as deposits of moneys for the purpose of paying estate duty as provided in clause (g) of Section 33 (1) of Estate Duty Act, 1953
and a receipt of the Government of India shall be an effectual discharge to the Insurer for the moneys so paid to them.
I undertake not to deal with the policy in any way so long as the above assignment is operative, except nominating any person to
receive the balance of the insurance proceeds, after satisfying the Estate Duty demand.
I, hereby certify that no prior assignment of the within policy or any encumbrance against it exists.

Dated (Signature/Thumbprint of Insurant)

Plac
Witness : Name & Address of witness:-

ID and address proof of witness is enclosed)

8. Appointment of Messenger (if loan application submitted by messenger)*:
I hereby declare that I, am unable to visit post office , being medically unfit
or outside India, for submission of loan application Name of
messenger) as a messenger for submission of my loan application and request you, please allow him/her for submission of the loan
application along with necessary documents.

Signature
Signature/Thumbprint of Insurant
Documents Enclosed: Yes/No/ NA (Not Applicable)
1 Self Attested copy of Policy Bond
Document (s) of Credit (if pay policy)
2 Or In case, any premia payment is made in addition to the details available in
Premium receipt book (if cash policy) loan quote
3 Self Attested copy of ID proof of the Insurant
4 Self Attested copy of address proof of the Insurant

5 Loan Repayment receipt Book (in case any loan re-payment is made in addition to the detail available in loan quote)

6 Cancelled Cheque of Insurant Bank Account for Bank Mandate Or self attested copy of POSB Passbook First Page

7 Self-Attested Copy of ID and address proof of Messenger (if messenger appointed by Insurant for submission of Loan
application form)
Self-Attested medical certificate of insurant from Govt. Hospital/Govt. accredited Hospital
8 Or for Appointing a
Self-Attested copy of passport clearly showing date of departure from India messenger
9
Date: ______________
Signature/Thumbprint of Insurant
In case Insurant is illiterate, there should be two literate witnesses-
Witness Name & Address Signature
Witness 1
Witness 2
For Official Use
Certified that I have checked all the documents enclosed and compared with the original document produced by the
Insurant/messenger and verified the averments made in the Loan application based on these documents and found no
discrepancies.
Date:- Signature of BPM/SPM/PM/ CPC in-Charge
Name:
Designation:
Office Stamp:
 APPLICATION FOR REVIVAL OF PLI/RPLI POLICY
(Please fill in the columns in block letters)

1. Policy No: _______________________________

2. Date of Acceptance: ________________________

2. Name of Insurant:_____________________________________

3. Present address for Correspondence: _________________________________________

_____________________________________________

_____________________________________________

Pin Code: _________________

4. Date of Maturity: ________________________

5. Mode of payment of premium : CASH OR CHEQUE/ PAY COVERY

6. Period for which premia are due: _____________________________________________

7. Reason for non-payment of premiums if any ____________________________________

8. Name of the Post Office at which premia are desired to be paid

Name of Sub Post Office: ________________________

Name of Head Post Office: ________________________

I hereby declare that I continue to be in good health since the date, the first
unpaid premium had become due in respect of above mentioned policy till this date.

Date:

Signature of insurant

List of Documents Enclosed: Medical Certificate

 MEDICAL CERTIFICATE FOR GOOD HEALTH

I have examined Sh./Smt.______________________________ on ___________ and found

him/her be in continuous good health.
Signature of the Insurant_________________

Place ______________________ (Signature of M.O.)

Date ______________________ Name:______________________ (in capital letters)
Desgn:

Seal & Date

FORM OF STATEMENT OF A RESPECTABLE PERSON

1. I ______________________________hereby certify that

Sh/Smt_____________________________ holder of Policy No._________________ is
personally known to us for the ______years and that there has been no adverse change in
personal or family history or occupation of Insurant. The
Insurant is not related to me.
Signature___________________________
Date:_______________________________
Occupation:_________________________

2. I ______________________________hereby certify that

Sh/Smt______________________________ holder of Policy No.__________________ is
personally known to us for the ______years and that there has been no adverse change in
personal or family history or occupation of Insurant. The
Insurant is not related to me.
Signature___________________________
Date:_______________________________
Occupation:_________________________

TO BE COMPLETED BY THE POST OFFICE

Policy No.________________ Amount Deposited: Rs.______________

Name of the Insurant_________________ On______________.ACG No.____________
I have checked the Medical Certificate & statements from 2(two) respectable persons as
appended above and found that these are completed in all respect.

Signature of Post Master

Rubber Stamp:
Date:
 APPLICATION FOR ISSUE OF FRESH PREMIUM RECEIPT BOOK

From

Contact No:

To

The Senior Postmaster /Postmaster

________________________(CPC
(CPC Name)

________________________

Sir,

As my PLI/RPLI premium receipt book was completed, kindly issue a fresh premium

receipt book to my Policy no__________________________.

no Old Premium receipt book is

enclosed herewith.

Date:

Place: Yours Faithfully,

…………………….
 APPLICATION FOR ISSUE OF DUPLICATE PREMIUM RECEIPT BOOK

From

Contact No:

To

The Senior Postmaster /Postmaster

________________________(CPC
(CPC Name)

________________________

Sir,

As my PLI/RPLI premium receipt book was lost during the house shifting/Fire
shifting accident,

no__________________________. The
kindly issue a duplicate premium receipt book to my Policy no__________________________.

premium for the policy was paid upto _______________. Necessary fee Rs.20/-
Rs.20/ for the same has

been paid and receipt enclosed herew

herewith.

Date:

Place: Yours Faithfully,

…………………….
 Annex-III
LETTER OF INDEMNITY

(To be executed by the Insurant in absence of Original Policy document)

I…………………………………………………… held myself and my family bound to

the Department of Posts (hereinafter called India Post), in the sum of
……………………………………………… (sum assured of the policy) of lawful money to
be paid on demand or without demand to India Post, its attorneys, successors or
assignees for which I bind myself, my executors, administrators, successors, and
representatives, firmly by this declaration.
Whereas on the …………………………………. day of …………………………….. I,
Sh./Smt./Ms.……………………………………………………… (the policy holder), purchased
from India Post, a PLI/RPLI Policy Numbered………………………………..of the sum
assured Rs.…………………………………… bearing a premium of
Rs.…………………per……………(month/quarter/half year/year) payable up to the
…………………………… (month & year) and I have applied to India Post for the
settlement of my Maturity claim and payment of money in respect of the said
policy AND Whereas the policy has been lost/untraceable and is not forth-
coming AND Whereas I have not produced the said policy issued to
……………………………………………………… (name of the Insurant) by India Post AND
Whereas I declare that the said policy has not been assigned or transferred to
anybody or disposed of in any other way with such consideration as here under
is written.

I hereby undertake to refund all the money with interest to India Post in
case of wrong information furnished above leading to unjust payment to me.

Provided further that the liability of sureties hereunder shall not be

impaired or discharged by reason of time being granted or any forbearance act or
omission of India Post or any person authorised by them (whether with or
without the consent or knowledge of the sureties) nor shall be necessary for
India Post to sue me (Claimant) before suing the sureties for amounts due
hereunder.

Signature/Thumb
Impression of the
Insurant
Name
Complete Address
Mob & email Id
Signed sealed and delivered by the above

Witness Name, Address and contact details Signature

Witness 1

Witness 2

Sureties Name, Address and contact details Signature

Surety 1

Surety 2

Signed sealed and delivered by the above

Witness for Name, Address and contact details Signature

Sureties

Witness 1

Witness 2

Note: Self Attested copy of ID proof and Address proof of all Sureties and
Witnesses are to be enclosed with this Letter of Indemnity.
 APPLICATION FOR BILLING METHOD CHANGE OF PLI/RPLI POLICY
(Please fill in the columns in block letters)

1. Policy No: _______________________________

2. Date of Acceptance: ________________________

3. Sum Assured: ______________________________

4. Name of the Insurant:______________________________________

5. Present address for Correspondence: _________________________________________

__________________________________________

___________________________________________

Pin Code: _________________

Mobile Number:

Email id:

6. Billing method requested for: Pay Recovery/ Cash or Cheque

I hereby declare that that above said is true in r/o above mentioned policy till this date

Documents enclosed:

 Original Policy Document

 Pay recovery Certificate/Premium receipt book

 Copy of Identity Proof /Address Proof

Date:
Signature of Insurant
 APPLICATION FOR BILLING FREQUENCY CHANGE OF PLI/RPLI POLICY
(Please fill in the columns in block letters)

1. Policy No:: _______________________________

2. Date of Acceptance: ________________________

3. Sum Assured: ______________________________

4. Name of the Insurant

Insurant:______________________________________
:______________________________________

5.. Present address for Correspondence: ____________

_________________________________________
_____________________________

__________________________________________
_____________________________

___________________________________________
______________________________

Pin Code: _________________

Mobile Number:

Email id:

6. Billing frequency requested for : Monthly / Quarterly / Half yearly / Yearly.

I hereby declare that that above said is true in r/o above mentioned policy till this date

Documents enclosed:

 Original Policy Document

 Pay recovery Certificate/Premium receipt book

 Copy of Identity Proof

Date:
Signature of Insurant
I
 APPLICATION FOR ADDRESS CHANGE OF PLI/RPLI POLICY
(Please fill in the columns in block letters)

1. Policy No : _______________________________

2. Date of Acceptance: ________________________

3. Sum Assured : _____________________________

4. Name of the Insurant:______________________________________

5. Present address for Correspondence: __________________________________________

_____________________________________________

_____________________________________________

Pin Code: _________________

Mobile No: _________________

6. Address in the original policy document: _______________________________________

____________________________________________

_____________________________________________

7. Actual Address to be incorporated: _____________________________________________

________________________________________________

________________________________________________

I have understood the meaning and scope of the address change request and
take complete responsibility of the changes submitted by me/us. Any changes in the
Policy/Personal details are subject to the policy terms and conditions and on
acceptance of relevant documents submitted.

Documents enclosed:

 Original Policy Document & Premium receipt book

 Copy of Address Proof (Aadhar Card/Voter ID/Driving License)
 Copy of Identity Proof (Aadhar Card/Voter ID/Driving License/PAN Card)

Date:
Signature of Insurant
 APPLICATION FOR NAME CHANGE ON PLI/RPLI POLICY
(Please fill in the columns in block letters)

1. Policy No : _______________________________

2. Date of Acceptance: ________________________

3. Sum Assured: _____________________________

4. Name of the Insurant:______________________________________

5. Present address for Correspondence: __________________________________________

_____________________________________________

_____________________________________________

Pin Code: _________________

Mobile No:__________________

6. Name in the original policy document: _______________________________________

7. Actual Name to be incorporated: _____________________________________________

8. Reason for Change __________________________________________________________

I have understood the meaning and scope of the name change request and take
complete responsibility of the changes submitted by me/us. Any changes in the
Policy/Personal details are subject to the policy terms and conditions and on
acceptance of relevant documents submitted.

Documents enclosed:

 Original Policy Document & Premium receipt book

 Copy of Gazette Notification
 Copy of Address Proof (Aadhar Card/Voter ID/Driving License)
 Copy of Identity Proof (Aadhar Card/Voter ID/Driving License/PAN Card)

Date:
Signature of Insurant
Request for Registration/ Change of Nomination in respect of PLI/ RPLI Policy
(refer Section 39 of Insurance act 1938) (Not applicable in case of policy under MWPA 1874)
(Please fill in the columns in CAPITAL letters)

1. Name of Insurant (Mr./ Mrs./ Ms.)

First Name Middle Name Last Name

2. Occupation

3. Communication Address

Village Taluka
City District
State Country PIN

4. Particulars of Policy:
i. Policy No. ii. Policy Type

iii. Sum Assured iv. Date of Acceptance v. Premium Ceasing Age

` / - / / Years

5. a. State particulars of the nominees (not more than three Nominees)

i. Sole/ First Nominee Details- (Mr./ Mrs./ Ms.)
First Name Middle Name Last Name

Relationship: Share %age: % Gender: M F

Date of Birth: / / Age: Years

Communication Address

Village Taluka
City District
State Country PIN

Phone No. E-mail ID (If any)

ii. Second First Nominee Details- (Mr./ Mrs./ Ms.)

First Name Middle Name Last Name

Relationship: Share %age: % Gender: M F

Date of Birth: / / Age: Years

Communication Address

Village Taluka
City District
State Country PIN

Phone No. E-mail ID (If any)

iii. Third Nominee Details- (Mr./ Mrs./ Ms.)
First Name Middle Name Last Name

Relationship: Share %age: % Gender: M F

Date of Birth: / / Age: Years

Communication Address

Village Taluka
City District
State Country PIN

Phone No. E-mail ID (If any)

b. Appointee Details (If nominee is minor)

First Name Middle Name Last Name

Relationship: Gender: M F

Date of Birth: / / Age: Years

Communication Address

Village Taluka
City District
State Country PIN

Phone No. E-mail ID (If any)

Date:________________
Signature of Insurant
Name:………………………
Phone no.: …………………
Office:………………………
Residence: …………………
Mobile no.: …………………

Signature of Witness 1:
Name:…………………………….
Phone no.:……………………….
Office:……………………………
Residence: ……………………..
Mobile no.:………………………

Signature of Witness 2:
Name:…………………………….
Phone no.:……………………….
Office:……………………………
Residence: ……………………..
Mobile no.:………………………
Form of Exercising Option for Conversion of WLA Policy into EA Policy
(Please fill in the columns in CAPITAL letters)
 Form of Exercising Option for Conversion of CWA Policy into EA Policy
(after completion of five years but within sixth year)
(Please fill in the columns in CAPITAL letters)

1. Name of Insurant (Mr./ Mrs./ Ms.)

First Name Middle Name Last Name

2. Occupation

3. Communication Address

Village Taluka
City District
State Country PIN

4. Particulars of Policy which has to be converted

i. Policy No.

ii. Sum Assured iii. Date of Acceptance iv. Premium Ceasing Age
` / - / / Years

5. Term of Endowment Assurance the insurant opts to convert the CWA policy by exercising the
option
EA (Fill here 50/ 55/ 58 in case of PLI or 50/ 55/ 58/ 60 in case of RPLI policy)

I, _______________________________________________ (Name) the holder of aforesaid

policy agree to pay the premium on enhanced rate towards my policy on conversion to Endowment
Assurance and also abide to accept the terms & conditions prescribed in Post Office Life Insurance
Rules-2011, as amended time-to-time by Director General of Posts.

Date:________________
Signature of Insurant
Name:………………………
Phone no.: …………………
Office:………………………
Residence: …………………
Mobile no.: …………………
Documents attached:

a) Policy document duly

b) Premium Receipt Book
d) Certificate of Pay Disbursing Officer regarding recovery of premia from pay for the last six months.
Form of Exercising Option for Conversion of Maturity Age in EA Policy
(Please fill in the columns in CAPITAL letters)
 APPLICATION FOR EXERCISING COMMUTATION IN PLI/RPLI POLICY
(Please fill in the columns in block letters)

1. Policy No:: _______________________________

2. Date of Acceptance: ________________________

3. Sum Assured: ______________________________

4. Premium Amount :__________________________

5. Name of the Insurant

Insurant:______________________________________
:______________________________________

6.. Present address for Correspondence: ____________

_________________________________________
_____________________________

__________________________________________
_____________________________

___________________________________________
______________________________

Pin Code: _________________

Mobile Number:

7. Commutation require
required: Change in Sum Assured / Change in Premium Amount .

Reduced Sum Assured: ___________________

Revised premium for the reduced Sum Assured: __________ (As per quote in McCamish)
Or
Reduced Premium Amount: ___________________
Revised Sum Assured for the reduced premium: __________(As
(As per quote in McCamish)

I ____________________________________(Name) the holder of aforesaid policy agree to

pay the revised premium towards my policy on commutation and also abide
abi to accept
the terms and conditions prescribed in POL
POLII Rules 2011,as amended time to time by
Director General of Posts.

Documents enclosed:

 Original Policy Document

 Pay recovery Certificate/Premium receipt book
 Copy of Identity Proof

Date:
Signature of Insurant
I
APPLICATION FOR UPDATION OF MOBILE NO /EMAIL ID IN PLI/RPLI POLICY
(Please fill in the columns in block letters)

1. Policy No:_________________________________________________

2. Name of the Insurant:_________________________________________

3. Mobile Number: _________________________

4. Email ID: _____________________________________________

I hereby declare that above said is true in r/o above mentioned policy till this date.

Date:

Signature of insurant

APPLICATION FOR UPDATION OF MOBILE NO /EMAIL ID IN PLI/RPLI POLICY

(Please fill in the columns in block letters)

1. Policy No:_________________________________________________

2. Name of the Insurant:_________________________________________

3. Mobile Number: _________________________

4. Email ID: _____________________________________________

I hereby declare that above said is true in r/o above mentioned policy till this date.

Date:

Signature of insurant
 APPLICATION FOR INCOME TAX STATEMENT

From To

The Senior Postmaster /Postmaster

________________________(CPC Name)
________________________

Contact No:

Sir,

Please issue Income tax certificate to my PLI/RPLI policy no._________

no.___________________________
for the financial year 20__ - 20__

Date:

Place

Thanking You,

Yours Faithfully,

…………………….

APPLICATION FOR INCOME TAX STATEMENT

From To

The Senior Postmaster /Postmaster

________________________(CPC Name)
________________________

Contact No:

Sir,

Please issue Income tax certificate to my PLI/RPLI policy no.___________________________

no.______________
for the financial year 20__ - 20__

Date:

Place

Thanking You,

Yours Faithfully,

…………………….
Annex - I

Claim Application Form for PLI/RPLI (Death Cases)

(Please fill in BLOCK Capitals)

Service Request No. :

(For Official Only)
1 Policy Details :

i Policy No. : ii Name of Insurant :

Date of Acceptance :
iii Sum Assured : iv
(dd/mm/yyyy)

Date of Survival Benefit Due : Date of Maturity :

v vi
(AEA Policy) (dd/mm/yyyy) (dd/mm/yyyyy)
Loan taken against policy : Yes No
vii
(if yes please attach Loan Repayment Receipt Book& fill column 2)
Date of Loan Repayment :
2. Loan Sanctioned Amount :
(dd/mm/yyyy)

3. Details of Death of Insurant:

Date of Death :
i ii Cause of Death :
(dd/mm/yyyy)

iii Place of Death (Full Address with Pin Code) :

4.(A) Details of Claimant-1:

Age of Claimant *:
i Name of Claimant : ii
(if Claimant is minor please fill column 5)

iii Relationship of Claimant with Insurant: iv Proof of Relationship ** :

v
Address:

District : State :

PIN Code : Mobile No :

Share of Claim
e-Mail ID :
amount (%) :

4.(B) Details of Claimant-2 (if Claimant is more than one):

Age of Claimant *:
i Name of Claimant: ii
(if Claimant is minor please fill column 5)

iii Relationship of Claimant with Insurant: iv Proof of Relationship ** :

v Address:

District : State :

PIN Code : Mobile No :

 Share of Claim
e-Mail ID :
amount (%) :

Details of Claimant-3 (if Claimant is more than

4.(C)
one):

Age of Claimant *:
i Name of Claimant : ii
(if Claimant is minor please fill column 5)

iii Relationship of Claimant with Insured : iv Proof of Relationship ** :

v Address:

District : State :

PIN Code : Mobile No :

Share of Claim
e-Mail ID :
amount (%) :

5. (A) To be filled If Claimant is a minor (A) if minor Claimant is more than one:

i Name of Guardian/ Appointee : ii Relationship with minor claimant :

iii Is Father of minor claimant deceased (Y/N): iv Is Mother of minor claimant deceased (Y/N):

5. (B) To be filled If Claimant is a minor (B) if minor Claimant is more than one:

i Name of Guardian/ Appointee : ii Relationship with minor claimant :

iii Is Father of minor claimant deceased (Y/N): iv Is Mother of minor claimant deceased (Y/N):

If you are not father or mother of the minor claimant, have you been appointed guardian of the minor claimant by nomination or

under any enactment in force in India? Please state and produce document in support of your claim
v
(Claimant A) _________________________________________________________________________________________

(Claimant B) _________________________________________________________________________________________

Does the minor claimant resides with you :

vi vii Is the minor maintained by you (Yes/No) :
(Yes/No)

6. Account Details (if payment desired through Bank Mandate)

Post Office Bank Account No. :

Name of Account Holder:

Name of Post Office/Bank: Branch:

IFSC code: Cancelled Cheque Enclosed (Y/N):

(*) Age of Claimant in completed years.

(**) Provide any valid document for proof of relationship between Insurant and Claimant.
Documents Enclosed: Yes/No/ NA(Not Applicable)

1. Original Policy Bond or Letter of Indemnity (Format at Annex III)

2. Self Attested copy of Death Certificate (issued by Local Administration/register of local board/village panchayat/Medical
Practitioner or Certificate of Doctor, who last attended the insurer clearly mentioning reason of death)

3. Self Attested copy of Succession Cert./Letter of Administration/Probate of Will, if nomination is not available

4. Self Attested copy of ID proof of the Claimant(s)

5. Self Attested copy of address proof of the Claimant(s)

6. Self Attested copy of FIR (in case of unnatural death of Insurant)

7. Self Attested Post-mortem report (in case of unnatural death of Insurant)

8. Cancelled Cheque of Claimant Bank Account(s) for Bank Mandate

9. Documents of Credit or Premium Receipt Book (D.O.C. if Pay policy or Premium Receipt Book if Cash Policy and all the paid

premium not updated on McCamish Software)

10. Loan Receipt Book (if Loan taken on Policy)

11. Indemnity Bond (in case of Unantural death)

12.

Date: ______________

Signature/Thumbprint of Claimant/Guardian of Claimant

In case Claimant/Guardian of Claimant is illiterate, there should be two literate witnesses-

Witness Name & Address Signature

Witness 1
Witness 2

----------------------------------------------------------------------------------------------------------------------------------------------------------------------

For Official Use

Certified that I have checked all the documents enclosed and compared with the original document produced by the claimant and
verified the averments made in the claim form based on these documents and found no discrepancies.

Date:- Signature of BPM/SPM/PM/ CPC in-Charge

Name :
Designation:
Office Stamp:
 Annex-III
LETTER OF INDEMNITY

(To be executed by the Claimant in absence of Original Policy document)

I…………………………………………………… held myself and my family bound to

the Department of Posts (hereinafter called India Post), in the sum of
……………………………………………… (sum assured of the policy) of lawful money to
be paid on demand or without demand to India Post, its attorneys, successors or
assignees for which I bind myself, my executors, administrators, successors, and
representatives, firmly by this declaration.
Whereas on the …………………………………. day of ……………………………..
Sh./Smt./Ms.……………………………………………………… (the policy holder), purchased
from India Post, a PLI/RPLI Policy Numbered………………………………..of the sum
assured Rs.…………………………………… bearing a premium of
Rs.…………………per……………(month/quarter/half year/year) payable up to the
…………………………… (month & year) in his/her name AND Whereas I, as the
nominee/legal heir have applied to India Post for the settlement of my claim and
payment of money in respect of the said policy AND Whereas the policy has been
lost and is not forth-coming AND Whereas I have not produced the said policy
issued to ……………………………………………………… (name of the Insurant) by India
Post AND Whereas I declare that the said policy has not been assigned or
transferred to anybody or disposed of in any other way with such consideration
as here under is written.

I hereby undertake to refund all the money with interest to India Post in
case of wrong information furnished above leading to unjust payment to me.

Provided further that the liability of sureties hereunder shall not be

impaired or discharged by reason of time being granted or any forbearance act or
omission of India Post or any person authorised by them (whether with or
without the consent or knowledge of the sureties) nor shall be necessary for
India Post to sue me (Claimant) before suing the sureties for amounts due
hereunder.

Signature/Thumb
Impression of the
Claimant
Name
Complete Address
Mob & email Id
Signed sealed and delivered by the above

Witness Name, Address and contact details Signature

Witness 1

Witness 2

Sureties Name, Address and contact details Signature

Surety 1

Surety 2

Signed sealed and delivered by the above

Witness for Name, Address and contact details Signature

Sureties

Witness 1

Witness 2

Note: Self Attested copy of ID proof and Address proof of all Sureties and
Witnesses are to be enclosed with this Letter of Indemnity.
Rs.10/- e Stamp Paper
Rs.100/- e Stamp Paper/
Non Judicial Stamp Paper
Rs.10/- e Stamp Paper/
Non Judicial Stamp Paper
(To be executed by the Claimant in case of claims without nomination and without succession certificate, on non-
judicial stamp paper of Rs. 50 or as prescribed in the circle concerned, whichever is higher)

AFFIDAVIT

I………………………………………… aged about…………, husband/wife/son/daughter etc of late……………… (name of

deceased policyholder), resident of…………………………………hereby solemnly affirm and declare the following:
1. That the said late deceased policyholder died intestate and did not leave any will.
2. That I am the only successor to the estate of the said deceased policyholder or all other legal
heir(s)/successor(s) have relinquished his/her/their interests & rights in the claim proceeds of the said
deceased policyholder in my favour.
3. That I have not submitted claim for any PLI or RPLI policy of the said deceased policyholder with
Department of Posts.
4. The details of all PLI & RPLI policies of the said deceased holder is/are as follows:

Sl. Policy Type of Sum Assured Date of

number policy/plan Acceptance

5. I hereby held myself and my family bound to the Department of Posts (hereinafter called India Post) for the
sum equal to the total claim amount, to be paid on demand or without demand to India Post, its attorneys,
successors or assigns or representatives for which I bind myself, my executors, administrators, successors,
and representatives, firmly by this declaration.
6. In case any information is found to be wrong, misleading or deceptive in any manner, at any stage, before
or after settlement of claim, my claim may be rejected or I shall be liable to refund all the money (total claim
amount received) with interest to India Post, as the case may be, and shall also be liable to be prosecuted
under relevant provisions of laws.
I solemnly state that the contents of this affidavit are true to the best of my knowledge and belief and that it
conceals nothing and that no part of it is false.
Dated:
Place:
Deponent

Notary Public
 Annex-VI
INDEMNITY BOND

(To be executed by the Claimant in case of Unnatural death of Insurant)

I…………………………………………………… hereby solemnly affirm and declare

that, I am neither involved in nor responsible for, directly or indirectly, death of
the Insurant for the policy number ………………………… for sum assured Rs.
……………………….. I am neither named as suspect/accused nor proposed to be
named as suspect/accused by the Police in the death case of the Insurant.

I hereby held myself and my family bound to the Department of Posts

(hereinafter called India Post) for the sum of ………………………………………………
(sum assured of the policy) along with bonus amount to be paid on demand or
without demand to India Post, its attorneys, successors or assigns or
representatives for which I bind myself, my executors, administrators,
successors, and representatives, firmly by this declaration.

I hereby undertake to refund all the money (sum assured along with bonus
amount paid) with interest to India Post in case of wrong information furnished
above or in case I am later convicted by the Court of Law in the death case of the
Insurant.

Provided further that the liability of sureties hereunder shall not be

impaired or discharged by reason of time being granted or any forbearance act or
omission of India Post or any person authorised by them (whether with or
without the consent or knowledge of the sureties) nor shall be necessary for
India Post to sue me (Claimant) before suing the sureties for amounts due
hereunder.

Signature/Thumb
Impression of the
Claimant
Name
Complete Address
Mob & email Id

Signed sealed and delivered by the above

Witness Name, Address and contact details Signature

Witness 1

Witness 2

Sureties Name, Address and contact details Signature

Surety 1

Surety 2

Signed sealed and delivered by the above

Witness for Name, Address and contact details Signature

Sureties

Witness 1

Witness 2

Note: Self Attested copy of ID proof and Address proof of all Sureties and
Witnesses are to be enclosed with this Indemnity Bond.