Annexure - I

STATE LIFE INSURANCE CORPORATION OF PAKISTAN

GROUP & PENSIONS, KARACHI ZONE
CLAIM FORM FOR
IN-SERVICE EMPLOYEES, GOVERNMENT OF SINDH
6th Floor, State Life Building No. 2
Wallace Road, Off I.I. Chundrigar Road, Karachi.
Phone No. 021-9217176, 021-9217057 & 021-9217056

Claim No. GOS ___________

Full Name of the Deceased ______________________________________________________________
Father’s/Husband’s Name ______________________________________________________________
Designation _______________________ N.P.S No./Grade __________ Sum Assured _____________
Last Basic Pay drawn ________________ Name of Department _______________________________
Date of Appointment _________________ Date of Birth _______________ Date of Death __________
Name of Nominee __________________________________ NIC/CNIC No. ____________________
Name of Recipient of family Pension ________________________ NIC/CNIC No. ____________________
Name of Successor ___________________________________ NIC/CNIC No. ___________________
Name of Guardian ___________________________________ NIC/CNIC No. ___________________
Bank Account No. of Claimant ___________ Bank Branch Address ____________________________
Postal Address of Claimant ______________________________________________________________
Postal Address of Department ___________________________________________________________

The above particulars of the deceased employee of Government of Sindh have been verified
from his/her personal record and it is further certified that this claim is genuine.

SIGNATURE & SEAL OF

VERIFIED BY AUTHORISED OFFICER HEAD OF THE DEPARTMENT

Enclosures : -
a. Attested Copy of Death Certificate.
b. Claim Form (Annexure-1) duly completed and verified by authorized officer.
c. Attested copies of NIC / CNIC of deceased and Nominee /Recipient of family Pension /
Successor / Guardian.
d Original Nomination Form / Attested copy of Pension Book / Succession Certificate
Issued by the competent Court of Law.
e. Attested copy of complete Service Book or Last Pay Certificate or Computerized slips
issued by A.G/D.A.O for ascertaining Grade/BPS of the deceased at time of death.
f. If Nomination or Recipient of family pension is/are not available, then to submit the
details of family members as per Sindh Civil Servants Welfare Fund Ordinance (Annexure “D”).
Note : All the above documents should be attested by any Gazetted Officer.
 DESCRIPTIVE ROLL

Descriptive Roll of _______________________________________________

Husband / Wife / ______________ of ____________________________
Expired on _______________________________________________
District ______________________________________________

01. N A M E : _______________________________________
02. FATHER’S NAME : _______________________________________
03. AGE / DATE OF BIRTH : _______________________________________
04. R A C E : _______________________________________
05. H E I G H T : _______________________________________
06. C O L O U R : _______________________________________
07. MARK(S) OF IDENTIFICATION : _______________________________________
08. RESIDENTIAL ADDRESS : _______________________________________
_______________________________________
09. PLACE OF PAYYMENT (GOVERNMENT
TREASURY OF SUB-TREASURY) : _______________________________________

10. SPECIMEN SIGNATURE : _______________________________________

11. THUMB & FINGER IMPRESSIONS

OF LEFT HAND

SMALL FINGER _________________ RING FINGER _________________

MIDDLE FINGE ___________________ FORE FINGER __________________

THUMB __________________

SIGNATURE ____________________

PHOTO-GRAPH NAME ____________________

(FRONT SIDE ________________ of Late ________
TO BE ATTESTED)
______________________________
 NO DUES CERTIFICATE
NO DEMAND CERTIFICATE

This is to certify :-

(1). That NO DUES are out-standing against Mr./Mrs./Mst. _________________

_____________________________________________________________ ,
.

(2). That NO OVER PAYMENT has been made to him / her.

(3). That he/she has not caused any financial loss to the Government.

(4). That he/she has not committed any financial irregularities.

(5). That NO AUDIT OBSERVATION is out-standing/pending against him/her.

………………………….
H.M./D.D.O.

_______________________________________________________________________

NO ENQUIRY CERTIFICATE

This is to certify as under :

(01). That NO DEPARTMENTAL and ANTI-CORRUPTION enquires are

out-standing/pending against Mr./Mrs./Mst. ________________________
_____________________________________________________________ ,

(02). That NO COURT CASE is out-standing/pending against him/her.

(03). That NO DISCIPLINARY ACTION is to be taken against him/her.

...………………………..
H.M./D.D.O.
 NO RE-MARRIAGE CERTIFICATE

This is to certify that Mr./Mst._______________________________________,

___________________ , ______________________________________________________

________________________ , expired on ________________________ . His/Her

widow/widower _____________________________________________________ holding

C.N.I.C Number ___________________________ has not yet re-married any man/woman.

….……………………………
H.M./D.D.O.
 Annexure "C"

GOVERNMENT OF _________________________

(Department/Office)

Dated : ___________________
Dear Sir,
Re: Group Insurance Policy for the Employees of the Govt. of __________________________
Claim No. GOC/GOB __________________________________________________________
With reference to the above noted Policy, I have to report that Mr./Mrs./Miss ________________

aged ________________ years who was workin gin this school/office as ____________________________
(State ageat death) (Designation)
on ______________________ due to _________________________________.
(State Date of death) (State exact cause of death)

It is, therefore, requested that a sum of Rs ________________ ( Rupees ____________________

only)
The amount for which the deceased was covered may be paid to the nominee/nominees. The original
nomination from his/her service record is enclosed.

It is hereby certified that :-

(01). The deceased died during service.
(02). The deceased was appointed on _______________ .
(03). At the time of the death the decased was a class ___________________ employee.
(04). His/Her last basic pay was Rs. __________ in the NPS No./Grade ____________
(05). He/She was not a contingent or work-charge employee.
(06). The deceased did not fill in nomination form in favour of any of his/her relatives
during his life time.
(07). The deceased was a subscriber to the fund.
(08). The claim has not been lodged by us earlier.
(09). The deceased was a permanent employee of Government of Sindh at the time of death.
(10). In case of retiree :
(i) Exact date of retirement ___________________ .
(ii) The basic pay of the deceased was Rs. __________ in NPS No./Grade ________
(iii) If the employee retired prematurely, his/her date of retirement ________________
(iv) Cause of pre-mature retirement ___________________________

Yours faithfully,

Head of Office/Department
(Signed and Sealed)

Address :

Phone :
Fax :
E-mail :
 ANNEXURE "D"
6th Floor, State Life Building No. 2,
Wallace Road, Off. I.I. Chundrigar Road, Karachi
Telephones : 9217057
UAN : 111-555-888 Ext. 3253
Fa : 9217096-9217177
CLAIM NO. GOS/GOB ________________________________________________________________________
GROUP TERM INSURANCE POLICY FOR THE EMPLOYEES OF GOVERNMENT OF __________________________
__________________________________________________________________________________________
With reference to the above-noted policy, I have to report that Mr./Mrs./Miss __________________________
_________________ aged __________ years who was working in this office/school as ____________________________
died of ______________________________________ on _____________________ .
It is, therefore, requested that the payment of Rs. ____________ (Rupees ______________________________
_____________________________________________ only). The amount for which the deceased was covered may be
made in favour of the family members of the deceased Government Servant.
It is hereby certified that :-
1 The deceasewd died during service.
2 The deceased was appointed on _________________________ .
3 At the time of the death the deceased was Class _________________________ employee.
4 His/Her last basic pay was Rs. __________ in the NPS No./Grade ____________
5 He/She was not a contingent or work-charge employee.
6 The deceased did not fill in nomination form in favour of any of his/her relatives during his/her life time.
7 The deceased was a subscriber to the fund.
8 The claim has not been lodged by us earlier.
9 The deceased was a permanent employee of Government of Sindh at the time of death.
10 In case of retiree :
(i) Exact date of retirement ______________________ .
(ii) The basic pay of the deceased was Rs. __________ in NPS No./Grade ________
(iii) If the employee retired prematurely, his/her date of retirement ________________
(iv) Cause of pre-mature retirement ___________________________
( i ) Name(s) of the wife/wives / Husband and her/their/his age(s) :
N a m e Relation-ship A g e
1)
2)
( ii ) Names of the legitimate children and step children less than twelve year. (Please give their ages).
N a m e Relation-ship A g e
1)
2)
3)
4)
5)
(iii) Names of the legitimate children and step children not less that 12 years old, if residing with and
wholl dependedntnupon him/her. Please give their ages and marital status.
N a m e Relation-ship Age Whether resided with and wholly
dependent upon him or her
1)
2)
3)
4)
5)
(iv) Name of the parents, sisiters and minor brothers, if residing with and wholly dependent upon him or her.
N a m e Relation-ship Age Whether resided with and wholly
dependent upon him or her
1)
2)
3)
Yours faith-fully,

Beneficiary Address : Head of Office/Head of Department

(Signed & Sealed)

Postal Address : _______________________________

Phone # : _______________________________
Fax # : _______________________________