Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims) (Page 2 of 6) in pdf

Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims) Page 2

(B) Claimant Details:

Name of the Claimant: ________________________________________ Age: ___________

Photograph

Nature of title: (Tick applicable box)

of Claimant

Nominee

Executor

Administrator

Trustee

Appointee

Employer

Assignee

Relationship with Life Insured: ___________________________________________________

(Please furnish Claimant ID Proof & documentary evidence establishing relationship with the Life Assured

relationship with the Life Assured)

Address for correspondence:

_____________________________________________________________________________________________

(Current Residential Address should match with address proof provided)

Contact no. (Res): ____________________________________Mobile: ___________________________________

Business Tel: ________________________________________Email id: __________________________________

Contact details provided herein will be updated for all future communications. For customers registered under the

National Do Not Call Registry, this response will be treated as a valid discharge.

1. (a) What was the occupation and Annual Income of the Life Insured ?

______________________________________________________________________________

(b) Employer’s / Life Insured’s business Address & Contact Details:

_____________________________________________________________________________

______________________________________________________________________________

2. (a) Was the Life Insured a smoker? Yes / No. (Strike of whichever is not applicable)

(b) If yes, since when & consumption per day

____________________________________________________________________

(d) If yes, since when & consumption per day

_____________________________________________________________________________________________

3. State all the facts regarding the cause and circumstances of Death

_____________________________________________________________________________________________

Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims) Page 2