For the Sheep Under SPECIAL SCHEME PACKAGE

FORMAT -1

National Insurance Co. Ltd

CLAIM FORM cum DEATH CERTIFICATE with POST MORTEM Findings and ADVANCE DISCHARGE VOUCHER

for the sheep under SPECIAL SCHEME PACKAGE

01. / Name of the Insured/ beneficiary (in full)
(as appearing in the Aadhar Form)
02. / Aadhar No.
03. / Mobile number of Beneficiary
04. / Village Mandal & District
05. / Policy No.
06. / Policy period / From / To
07. / Date & Time of Death of animal
08. / Date & Time of Claim Intimation
09. / Description of animal claimed for:
Ear Tag Number / Sheep/Ram / Age of animal / Sum Insured
10. / a) Whether photograph of dead animal is been attached
b)Whether live animal photograph at the time of insuring the animal is uploaded in the website
b) One photograph of dead animal is been uploaded in the website / Yes/No
11. / Collector/Beneficiary Bank Details as the case may be into which the claim proceeds be transferred
Name of Bank / Name of Branch / IFSC Code / Account No.
Check-list of Documents/other requirements to be submitted along with CDC
(1)  Ear tag
(2)  Photographs as detailed above(10a)
(3)  MRO Certificate/ FIR (in case of accident & AOG Peril / As applicable
Date / Signature of the Official / Signature/Thumb Impression of Beneficiary
Post-mortem Certificate
I certify that the animal described above died and post-mortem was conducted by me as detailed hereunder:
A) / Date & Time of Death of animal
B) / Whether animal died in Transit (Yes/No)
B) / Date & Time of Conducting post-mortem
C) / Post-mortem No. as per Post-mortem register
D) / Post-mortem findings
E) / Cause of death as per Post-mortem
Date / Signature & Seal of the VAS
Mobile number of VAS…………………………………………………………………
Claim Discharge Voucher
Received with thanks an amount of Rs.______(Rupees ______only) from National Insurance Co. Ltd. towards full & final settlement for claim No.______for the death of sheep with tag number ______.
Date: Signature/Thumb Impression of beneficiary