Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims) printable pdf download

Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims)

BIRLA SUN LIFE INSURANCE COMPANY LIMITED

CLAIMANT’S STATEMENT FORM (DEATH CLAIMS)

Points to Note

This form is to be filled in by the beneficiary under the policy or by the person legally entitled for the due

•

policy proceeds.

All answers must be clear & unambiguous.

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To initiate the claim processing please submit all documents in complete form. Incomplete form(s) will not

•

be accepted

Submission of this form will not be construed as acceptance of claim by the company. The Company

•

reserves the right to call for additional document/ requirements

The person filling this form must be the claimant. If the claimant is minor, the guardian/ appointee may fill

•

the form

Any overwriting must be countersigned by the claimant.

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No agent has been authorized to admit any liabilities on behalf of Birla Sun Life Insurance Company

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Limited.

Documents to be submitted

Mandatory Requirement:

Basic Requirements:

1. Copy of Death Certificate issued by Municipal

1. Original Policy Document

Authority / Gram Panchayat

2. Claimant’s ID, Address Proof & Relationship Proof

Additional Requirements:

Additional Requirements for Accidental Death:

1. Medical Attendant Certificate

1. First Information Report

2. Employer’s Certificate (if employed)

2. Post Mortem Report

3. Police Inquest Report

4. News Paper Cutting (if any)

BSLI Reserves the right to call for additional requirement(s) depending on the peculiarity of the case

(A) Life Insured's Details:

Policy No.(s): ________________________________________________________________________________

Name of the Life Insured in full: _____________________________________________ Age (in Yrs.): ________

Date of death: ________________ Time of death: ____A.M. / P.M Cause of death: ________________________

Place of death (If hospital or institution, give name, address & contact number):

_____________________________________________________________________________________________

In case of accidental death:

Date of Accident: ______________Nature of Accident: Road/ Rail/ Air/ Other (specify) ______________________

Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims)

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