Form No. 3054 (Re)
VELLORE DIVISION
FORM OF NOMINATION
I of Insurance agent (Agency Code No. ) attached to Branch of Vellore Division of the Life Insurance Corporation of India ("here in after known as the Corporation") do hereby nominate under sub section (4) of section 44 of the insurance Act 1938 as made applicable to the Corporation by notification in the Gazette of India dated 27-04-1972 and as amended from time, to time, the person / person as shown under section I / II below (strike off the section not applicable) to whom the moneys found to be due and payable on my death and there after shall be paid and direct that his / her their receipt there of for the moneys against the respective item/s shall be a full and sufficient discharge to the Corporation.
2. In case the said nominee/s mentioned in column 3 below shall die during my life time, then appoint the persons whose name/s is / are set out against the respective nominee/s column 5 as the alternate nominee/s to receive moneys payable at my death and there after.
| Item | Moneys due and payable | Nominee | Alternate Nominee | ||
|---|---|---|---|---|---|
| Name | Relationship with Agent Age & Address | Name | Relationship with Agent Age & Address | ||
| SECTION - 1 TO RECEIVE ALL DUES | |||||
| Gratuity Term Assurance Claim Amount and all Commission payable at death and there after | |||||
| SECTION - II SEPARATE NOMINEES FOR DIFFERENT DUES | |||||
| (i) | Gratuity | ||||
| (ii) | Term Assurance / Claim Amount | ||||
| (iii) | All Commission payable at death and there after | ||||
3. This nomination supersedes the nomination - made by me earlier and registered in the books of your Branch / Division under Serial No. on which is here by cancelled.
Signed at
this
day of
20
Witness :
Signature:
Full Name:
Occupation:
Address:
Signature of the Agent
P.T.O.
INSTRUCTIONS
1) After filling up the blanks as may be necessary in the Form of Nomination the Agent should affix his signature thereon which should be witnessed in the space provided for by an English knowing person. In case the form of Nomination has been signed by the Agent in any language other than English the witness should also certify as follows:
*Certified that the contents of the above have been explained by me to the agent Shri. / Smt. in the Agent's mother-tongue and that he / she has affixed his / her signature there to in my presence after fully understanding the same*
Signature:
Full Name:
Occupation:
Address:
2) If it is a first nomination, Strike out para 3 under full signature.
3) Immediately after nomination or Change of nomination has been effected it should be registered. A nomination will not be effective unless it is registered by the Corporation and the Corporation shall not be liable for payment made to any other person in case the nomination is not so registered.
4) In registering a nomination, the Corporation makes no admission and expresses no opinion whatever as to its validity or effect it being understood that the parties satisfy themselves as to the form of nomination and all other points relating to the nomination before sending it to the office for registration.
5) In registering a nomination, the Corporation does not admit liability for payment of commission or any other moneys in the event of death of the agent. The liability of the Corporation for payment of commission or any other moneys in the event of death of the agent would be determined solely by the fact whether or not the agent has qualified for such payment at the times of his death under sec. 44(1) (b) (bbb) or ) of the Insurance Act 1938 (as made applicable to the Life Insurance Corporation of India by Notification in Gazette of India dated 27-04-1972) or under the Life Insurance Corporation of India (Agents) Rules 1972 (as amended from time to time)