Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims) (Page 4 of 6) in pdf

Advance Discharge Receipt

I/ We __________________________________________________________ the nominee (s)/ Assignee (s)/ Legal

Representatives of the above named Life Insured, do hereby acknowledge receipt from the Birla Sun Life Insurance

Company of the sum of Rupees (in words) ____________________________________________________towards

the full and final settlement and discharge of all my/ our claims and demands under the above mentioned Policy.

Date ___________________________

Revenue

Claimant’s Name & Signature _____________________________________

Stamp

Declarations

I hereby notify the Birla Sun Life Insurance Co. Ltd. that Mr./Ms./Master ____________________________ whose

life was insured by the said company, under policy no. ________________ is no more and I hereby declare that the

said person is the Life Insured described above and that the aforesaid answers and statements made by me are true

and correct. I agree that furnishing of this form, or any forms supplemental thereto, shall not constitute nor be

considered an admission by Birla Sun Life Insurance Co. Ltd. that there was any assurance in force on the life in

question or of its liability there under, nor a waiver of any of its rights or defense.

I hereby authorize any physician, hospital, clinic, insurance company or other organization, institution or person,

that has any record of the deceased or his health, to give to Birla Sun Life Insurance Company Limited, any and all

information about the deceased with reference to his health and medical history and any hospitalization, advice,

diagnosis, treatment, disease or ailment. I further authorize the Employers (past and present) of the Life Insured to

furnish to Birla Sun Life Insurance Company Limited, details of the leave availed of by the Life Insured during the

last three years of his service together with copies of the leave applications and medical certificates, if any,

submitted by the Life Insured in support of such applications and details of reimbursement of medical expenses. I

also consent to a personal investigation.

Date _______________Signed at ________________Signature of Claimant _____________________________

Witness: Name: ___________________________________________ Signature: _________________________

Declaration to be made by Third Person where the claimant signs in vernacular or affix a thumb

impression or has not filled the form:

I hereby certify that the contents of this form were explained to the claimant in ____________ language and have

truthfully recorded the answers provided to me. The claimant has affixed his/her impression in my presence

Declarant Name & Signature:

Date:

Place:

Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims) Page 4