Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims) (Page 3 of 6) in pdf

Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims) Page 3

4. If the life insured was ill prior to his death, state the nature and the duration of illness with date of diagnosis and

names of doctors consulted in last 3 years. (Please provide self attested copies of all the medical reports)

Date of Consultation

Name of treating Doctor /

Nature of complaint

Date of Diagnosis

Hospital & Address

5. Was the insured covered under any other Life insurance/ Health insurance/ Medi-claim/ personal accident

insurance with any other company? If yes, give following details.

Policy No.

Policy issue date

Name of Insurance

Total Cover

Has the Claim

Benefits Received

company

been lodged (Yes/

(Yes / No)

No)

6. Did the insured leave a will? - Yes/ No (Strike of whichever is not applicable)

If yes please submit the copy of will along with this form.

7. PEP – State whether the Beneficiary are Politically Exposed Person

Yes

PEP. “Individuals who are or have been entrusted with prominent public functions, for example Heads of State or

government, senior politicians, senior government, judicial or military officials. Senior executives or state – owned

corporation and important political part officials. Business relationships with family members or close associates of

PEP’s involving reputation risk is similar to those with PEP’s themselves”

Pension Option Form (

To be filled only in case of Pension Policies with or without life cover if spouse is

the nominee)

Please select one of the options below by ticking the appropriate box and submit the form at the above address. The

payment will be subject to tax liability, if any.

Receive the entire death benefit as a lump sum or

Receive 1/3 rd of the death benefit in a lump sum and utilize the balance to purchase an Annuity or

Utilize the entire death benefit to purchase an Annuity

For more details on risk factors, terms and conditions please read the sales brochure carefully of the then available

annuity plan or consult our Insurance Advisor.

Please note if the pension policy under claim is issued prior to 1

January 2012, annuity can be purchased from any

annuity provider, or else it should be purchased only from BSLI.

Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims) Page 3