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INDIVIDUAL-DEATH-CLAIM-FORM-A.pdf
- 1. INDIVIDUAL DEATH CLAIM FORM SECTION A* POLICY DETAILS Policy Number (s): _________________________________________________________________________________________________________ SECTION B* DETAILS OF LIFE ASSURED (LA) Name of Life Assured: Mr. Ms. ______________________________________________________________________________________ Father's/Spouse Name: _____________________________________________________________________________________________________ Date of Death: ______________________________________________ Time of Death: _______________________________________ Place of Death: Hospital Clinic Residence Office Other (Please specify): _____________________ Family Doctor: Name _____________________ Registration Number _________________________ Contact No. __________________________ Last treated/attended Doctor: Name __________________ Registration Number _______________________ Contact No. __________________ Last Employer details (If applicable): Name of the Company ___________________________ Name of contact person ____________________ Contact No. _____________________ Nature of Death Medical Natural Accident Murder Suicide Cause of Death ___________________________________________________________________________________________________________ Nature of Illness and Habit of the insured Date of diagnosis of illness Hypertension Diabetes Heart disease Liver disease Kidney disease Cancer Other _______________________ Smoking Tobacco Drugs, if yes, Duration of Consumption________________ & Quantity Consumed Other Insurance details: (Life/Mediclaim/Health) Policy No. Company Name Sum Assured Status (Active/Lapsed/Applied/Matured) Claims status DETAILS OF CLAIMANT Claimant Name: __________________________________________________________________________________________________________ Date of Birth: _______________________ Address: ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ For Office Use Only Branch Name: __________________________________________________ Branch Code: _________________ Employee Name: ________________________________________________________________________________ Employee Code: ______________________________________ Sign: __________________________________ Date: _____________________________ Time: On or before 3PM After 3PM Photograph of Claimant D D M M Y Y Y Y F I R S T M I D D L E L A S T F I R S T M I D D L E L A S T F I R S T M I D D L E L A S T D D M M Y Y Y Y D D M M Y Y Y Y
- 2. IFSC Code (11Characters) Account Holders Name MICR Code (9 Characters) Pincode: ____________________________________ Contact No.: _____________________________________________________________________________________________________________ Office & / or Personal Email ID: _____________________________________________________________________________________________ Relation with the Life Assured: Spouse Children Parents Others ______________________________ Claimants Title: Nominee Executor Trustee Appointee Employer Assignee Beneficiary Claimant's PAN details: or Form 60 Politically exposed person: Yes No US Person: Yes No (If Yes, please fill FATCA / CRS certification) CLAIMANT NEFT MANDATE/ BANK ACCOUNT DETAILS In case of children's plans, if beneficiary is a major, please provide beneficiary's account details Bank Account No.: _______________________________________________ Account Holder Name: ___________________________________________ Bank Name & Branch: ____________________________________________ Account Type Savings Current NRO NRE IFSC: _________________________ MIRC: ___________________________ Blank space for companies to input product specific payout methods SECTION C* DECLARATION AND AUTHORISATION I here declare all the details filled/furnished above are true correct to the best of my knowledge & belief. I hereby warrant the truth and correctness of the foregoing particulars in every respect, and I agree that if I have made or shall make any false or untrue statement, suppress or conceal any material fact, my right to claim reimbursement of the said expenses shall be absolutely forfeited. I understand and agree that the submission of this form does not mean that the request will be processed. I understand that any payout under the policy shall be strictly in accordance with the policy terms and conditions. Any payment shall be subject to realization of the last renewal premium payment. I authorise all the medical establishments (medical labs included), government institutions (police, revenue, etc.) to reveal the treatment information including HIV/AIDS and others, related to the LA, to MAX LIFE INSURANCE, from both the past and present. A photocopy of this declaration shall be considered as valid and effective. I authorise MAX LIFE INSURANCE to share and obtain information on behalf of me with any reinsurer, insurance association, medical authorities, other insurers, statutory authorities, employer, court, governmental body, regulator using an investigation agency or other service hereby provide my consent for the same. Date: __________________________ Place: _________________________ Signature of Claimant DECLARATION TO BE MADE BY A THIRD PERSON The Policyholder has affixed his/her thumb impression/has signed in vernacular/has not filled the application. I hereby declare that the content of this application form has been explained to the Policyholder in _________________________ language and have truthfully recorded the answers provided to me. I further declare that the Policyholder has signed/affixed his/her thumb impression in my presence. Name of the Declarant: ______________________________________________________________ Address: ___________________________________________________________________________ Date: __________________________ Place: _________________________ Signature of Third Person D D M M Y Y Y Y D D M M Y Y Y Y
- 3. Important Note: In case of any demand or favour asked by anyone including a company representative towards claim processing or settlement, the same should not be entertained and must be reported to the company immediately on the companys email id: claims.support@maxlifeinsurance.com INSTRUCTION FOR FILLING UP THE FORM A. IMPORTANT INFORMATION (Please read before filling the form) 1. The form should be filled by the claimant only. In case the claimant is a minor, the guardian/appointee may fill the form 2. Claims under multiple policies may be registered by filling a single form & providing all applicable policy numbers 3. In case of more than one claimant, separate forms need to be filled for each claimant 4. Please read the declarations carefully and the claimant should sign the claim form in the same manner as you normally sign your cheque 5. Claim is payable subject to fulfillment of all terms and conditions of the policy 6. No fee or commission should be paid to anyone to process this claim 7. Make sure your address, phone numbers and email ID are current and active as the correspondence will happen through this only 8. Asterisk (*) refers to mandatory information B. DOCUMENTS TO BE SUBMITTED MANDATORY DOCUMENTS 1. Original policy document (Not necessary in case of dematerialised policy document) 2. Death certificate issued by local authority 3. Claimant's PAN CARD 4. Claimant's passport size photograph 5. Cancelled cheque ADDITIONAL DOCUMENTS HOSPITALISATION/ DEATH DUE TO ILLNESS 1. Medical cause of death certificate 2. Medical records for all the treatments taken in the past. (Admission notes, History / Progress sheet, Discharge / Death summary, Test reports, etc.) 3. Claimant's passport size photograph 4. Cancelled cheque ACCIDENTAL DEATH First Information Report (FIR), Panchnama / Inquest report, Post-mortem report (PMR), Driving license, Police Final Report, Viscera report (if applicable) Newspaper cutting (s), if any, Others as applicable Disclaimers: 1. Copies to be submitted and originals to be presented at the time claim submission, 2. MAX LIFE INSURANCE reserves the right to ask for more information/ documents, if required C. LIST OF VALID IDENTITY & ADDRESS PROOFS (Please tick the document submitted) PHOTO IDENTIFY PROOF (ANY ONE) ADDRESS PROOF (ANY ONE) Claimants PAN Card Valid Passport Voter ID Valid Passport Aadhar Card* Valid Driving License Voter ID Bank Passbook with stamped photograph (not more than 6 months old) Aadhar Card* ID Card Issued by Central/State Govt. to employees Valid Driving License Any other Central/State Govt. issued ID Bank Passbook with stamped photograph (not more than 6 months old) *I voluntarily provide my consent to use my Aadhar to conduct identity check towards KYC compliance by MAX LIFE INSURANCE. D. NOTE: CLAIMANT NEFT MANDATE/ BANK ACCOUNT DETAILS A cancelled personalised cheque with the account no. and IFSC should be submitted along with the NEFT mandate. If the cheque is not personalised, a latest bank statement or copy of passbook (where account number and IFSC is mentioned) needs to be submitted with the mandate. This mandate, upon processing, will override any of the previously tagged NEFT mandates for all policies, held by the client with (MAX LIFE INSURANCE) Life. In case of NEFT failure or any further requirements pending on the mandate, payout will be kept on hold till fresh NEFT mandate is received. Intimation will be sent to you for the same. Refund to NRE account (full or proportionate) will be subject to ratio of premium(s) paid through NRE Account. Please submit a Bank Statement or Bank Confirmation letter as evidence for premium(s) paid through NRE account. ##In case of proportionate payout, please provide two NEFT mandates i.e. for NRE account and non-NRE account
- 4. CUSTOMER ACKNOWLEDGEMENT COPY-INDIVIDUAL DEATH CLAIM FORM Policy No. ________________________________________________________ Claimant Name __________________________________________ Branch Name _____________________________________________________________________________________________________________ Employee Name ___________________________________________________ Date ___________________________________________________ Employee Sign ____________________________________________________ Employee Code __________________________________________ _________________________________________________________________________________________________________________________ BEWARE OF SPURIOUS / FRAUD PHONE CALLS: IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving such phone calls are requested to lodge a police complaint. BRANCH STAMP