INDIVIDUAL DEATH CLAIM FORM

Transcription

1 H or fficial se nly ranch ode: ranch ame: nteraction : ate: n or efore 3 ime: fter 3 mployee ame: ign: mployee ode: lease accept our condolences on your untimely loss. We understand that this is a difficult time for you and it is our responsibility to offer you the best support in this hour of need. his eath laim form will help you file your claim with ease. lease submit this form duly filled and signed with appropriate documents and follow the instructions below to help us settle your claim at the earliest. 1. he form should be filled by the claimant only. n case the claimant is a minor, the guardianappointee may fill the form. 2. laims under multiple policies may be registered by filling a single form & providing all applicable policy numbers. 3. n case of more than one claimant, separate forms need to be filled for each claimant. 4. lease read the declarations carefully and sign the claim form in the same manner as you normally sign your cheque. 5. he laimant should sign in all pages of this laim form. 6. laim is payable subject to fulfillment of all terms and conditions of the policy. 7. o fee or commission should be paid to anyone to process this claim. 8. sterisk (*) refers to mandatory information. ension claim- ection,, mandatory to fill; eath claim (on- accidental) - ection,,,; eath claim (ccidental) - ll sections are mandatory for filling. H ll fields in the claim form should be filled by theclaimant in K letters. ection : etails of laimant and andate olicy umbers and letters should be unambiguous and legible. ake sure your address, phone numbers and are current and active as the correspondence will happen through this only. lease fill the orm completely and enclose a copy of cancelled chequebank account passbook to enable us to transfer the claim proceeds directly to your account subject to the claim being payable as per the terms and conditions of the policy. ection : etails of ife ssured Wherever you choose the option "thers", kindly specify the details in the given space. rovide supporting documents as and when requested. ection : Hospitalisation details of ife ssured or all medical reports, documents and certification issued by the attending physician, please ensure that heshe is qualified to provide such document certification according to ndian aws. oncealment of other insurance policies of ife ssured might lead to invalidation of the claim. ection : etails of death due to ccidenturderuicide rovide detailed account of the accident. nclosettach and, otherwise clearly state the reason why it is not available or provided. ection : eclaration and uthorisation rovide signature and contact details in the designated place. Keep the cknowledgment slip handy and produce it whenever the representatives of H ife ask for it. & ( K H ) ( ) H ( ) adhaar ard alid assport oter ard adhaar ard alid assport ard oter ard alid riving icence alid riving icense oter ard ank assbook with stamped photograph tility bill as address proof not more than 2 months. ard issued by entral tate ovt. to employees ank assbook with stamped photograph riginal policy document (ot necessary in case of dematerialised policy document) H H opy of death certificate issued by local authority opy of edical cause of death ertificate laimant's adhaar card and details edical records for all the treatments taken in the past. (dmission notes, Historyrogress sheet, ischarge eath summary, est reports, etc.) ife ssureds adhaar card and details H ancelled cheque, remationurial lip, mployee certificate in case ife ssured was alaried opy of irst nformation eport (), anchnama nquest report, ost-mortem laimant's passport size photograph report (), riving licence, olice inal eport, iscera report, if applicable, ews paper cutting (s), if any, thers as applicable isclaimer: H tandard ife nsurance ompany reserves the right to ask for more information documents, if required. H laimant ignature

2 * olicy umber(s):, laim form filling ssisted by:, H ife mployee olicy gent elatives lease affix recent passport size photo of the laimant f the option H ife mployee or elatives selected above, details elatives mployee ame : ontact: r. s. laimant ame: r. s. ate of irth: ddress: K.. ontact o.: usiness elf mployed ffice &or ersonal mail : ccupation details: ervice onthly income (): p to 20,000 elation with the ife ssured: laimant s itle: 20,001-50,000 pouse ominee hildren xecutor arents House wife 50,001-1,00,000 r >1,00,000 thers rustee laimant's : thers ppointee orm 60 mployer ssignee eneficiary orm 61 laimant's adhaar o.: s the laimant a olitically xposed erson ()? referred mode of ommunication: mail es o ": ersons who are members of senior management in a state owned enterprise, olitical party or an international organisation. i.e. directors, deputy directors and members of the board or equivalent functions" hysical etters (if is selected, no physical letters will be sent) K n case of children's plans, if beneficiary is a major, please provide beneficiary's account details. ank ccount o. : ccount Holder ame: ank ame & ranch: ccount ype avings urrent ll premium(s) paid from ccount: # ## roportionate premium(s) paid from ccount: ^: ^11 haracter code appearing on your cheque leaf ote: cancelled personalised cheque with the account no. and should be submitted along with the mandate. f the cheque is not personalised, a latest bank statement or copy of passbook (where account number and is mentioned) needs to be submitted with the mandate. his mandate, upon processing, will override any of the previously tagged mandates for all policies, held by the client with H ife. n case of failure or any further requirements pending on the mandate, payout will be kept on hold till fresh mandate is received. ntimation will be sent to you for the same. # efund to account (full or proportionate) will be subject to ratio of premium(s) paid through ccount. lease submit a ank tatement or ank onfirmation letter as an evidence for premium(s) paid through account. ## n case of proportionate payout, please provide two mandates i.e. for account and non- account. eclaration: 1. We hereby declare that the particulars given above are correct. f the transaction is delayed or not effected at all for reason of incomplete or incorrect information, we would not hold H tandard ife nsurance ompany imited ( H ife ) or any of its associatesagents responsible. urther, we agree to keep H ife indemnified against any loss caused to them due to any incorrect information provided above. 2. We further undertake to refund any excess amount whether demanded by H ife or not, which has been credited in excess to myour account at any time due to any reason. ate : H lace: ignature of laimant

3 * () ame of ife ssured: ather's ame: s. r. s and adhaar umber: ate of death: lace of death: ocation: lace of death address adhaar ge at death: Hospital work place ime of death: Home H H thers. : :... f death outside ndia, body transfer permission ertification from onsulate : vailable ot available f ot vailable,why? Whether burial or cremation certificate enclosedattached accordingly? : es o f ot vailable,why? lace of burialcrematorium address. ature of death: edical ccident urder uicide mmediate cause of death: ircumstances surrounding death: ame and contact details of relative present at time of deathcremationburial: 1st ame: ontact details: 2nd ame: ontact details: ccupation details: ervice onthly income () usiness p to 20,000 : elf-mployed 20,001-50,000 House wife thers: 50,001-1,00,000 >1,00,000 ame of mployer: Work placeemploymentbusiness address K.. ast working location employmentbusiness: ontact details of the mployer: ast Working day: H laimant ignature

4 H Was the life assured diagnosedsuffering fromtreated for the following illness? Hypertension iabetes ancer thers ate on which diseaseillness irst diagnosed Heart disease iver disease Kidney disease Have any of your immediate family members suffered from the similar illness? es o f yes, provide details when it was initially diagnosed: etails of treatment received including dates of outpatient or inpatient ype of admission: mergency lanned ay are aternity reatment given, if no surgery: Hospitalisation due to injury: es f yes, give cause: o elf-nflicted oad raffic ccident ischarged to Home tatus at the time of discharge: vailable edical cause of death certificate: ubstance buse ischarged to nother Hospital ot available eceased lease encloseattach. f not available, state the reason. H (or the last 5 years from policy isk ommencement ate) or more than one doctor consulted during the last 5 years from policy, please attach a separate page mentioning all the details. ame of octor: ddress of Hospital:.. ontact etails of octor: ates of onsultation: easons of onsultation: octor who attended the last illness: ddress of Hospital: ontact etails of octor: amily doctor: ddress of Hospital: ontact etails of octor: octor who declared death: ddress of Hospital: ontact etails of octor:..... H laimant ignature.

5 id the ife ssured have the habit of drinking, smoking andor chewing tobacco? eer Whiskey Wine thers: igarettes idi obacco utka f the ife ssured had drug habits: es thers: o f es, please provide details. mlbottle per day umber of years ame of drugs o. of sticks or packets per day ose usage ther substance addictions, if any: H olicy o. asic um ssured () ame f he nsurance ompany isk ommencement ate () laim tatus laim pplied laim ot pplied lease tick the appropriate boxes artial laim mount eceived egal ppeal filed against the claim ull laim laim mount enied eceived f claim not applied with other insurer, why? n case of death due to ccidenturderuicide ddress & contact details of police station where ase iary is registered: f not registered, state the reason: etails of hospital where ost ortem was conducted s the ost ortem report enclosedattached? etails of how the incident happened? es ail f not attached, kindly state the reason o oad ir thers etails of parties involved & location of the accident H ate : lace: laimant ignature

6 * H hereby declare all the details filled furnished above are true and correct to the best of my knowledge & belief. hereby warrant the truth and correctness of the foregoing particulars in every respect and agree that if 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. understand and agree that the submission of this form does not mean that the request will be processed. understand that any payout under the policy shall be strictly in accordance with the policy terms and conditions. ny payment shall be subject to realization of the last renewal premium payment. authorise all the medical establishments (medical labs included), government institutions (police, revenue, etc.) to reveal the treatment information including H and others, related to the, to H ife, from both the past and present. photo copy of this declaration shall be considered as valid and effective. authorise H ife 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 provider(s) for servicing insurance policy, underwriting risk, settlement of claim, etc. without obtaining my specific consent for such sharing and hereby provide my consent for the same. H ate : lace: H X HH H H H H hereby declare that have explained the contents of this application form to the laimant in language and have truthfully recorded the answers provided to me. further declare that the laimant has signedaffixed hisher thumb impression in my presence. hird arty ame : H ddress : ontact etails: ate : hird arty ignature lace: H tandard ife nsurance ompany imited ( H ife ). : 65110H egd. ff: 13th loor, odha xcelus, pollo ills ompound,.. Joshi arg, ahalaxmi, umbai egistration o ustomer cknowledgement opy-ndividual eath laim orm olicy o. ranch ame nteraction mployee ame mployee ign ame of laimant ate mployee ode ranch tamp riginal policy certificate emat olicy ertificate mployee certificate of ife ssured laimant's adhaar eath certificate by ife ssureds adhaar ancelled cheque irst nformation eport () esidential address proof anchnama ost ortem eport () inal report laimant's hoto omplete edical ecords urial or remation slip edical ause of death certificate thers isclaimer: H tandard ife nsurance ompany reserves the right to ask for more information documents, if required. H tandard ife nsurance ompany imited ( H ife ). : 65110H egistration o.101. egd. ff: 13th loor, odha xcelus, pollo ills ompound,.. Joshi arg, ahalaxmi, umbai all (local charges apply). prefix any country code e.g. +91 or 00. vailable on-at from 10 am to 7 pm mail service@hdfclife.com service@hdfclife.com (or customers only) isit