Application Form For Life Insurance (To be Submitted by Pensioner)

ANNEXURE-XVII

LIFE CERTIFICATE
(To be submitted by Pensioner once a year in November)

Certified that I have seen the pensioner ShrVSmt./Ms.
_ (Name of Pensioner)
holder of Pension Payment Order No. and that he/she is alive on this
date.

Name Place: Date:

Designation of Authorised Officer

Seal