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

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

No Objection Certificate

(To be signed by the Claimant)

Date:

To,

_____________________________

SUB: NO OBJECTION CERTIFICATE FOR OBTAINING ALL DOCUMENTS PERTAINING TO DEATH

CLAIM

MR./MS.________________________________________UNDER

POLICY

NO.

____________________

I, Mr. /Ms. ____________________________________________________________________________(name of

Claimant) __________________________(relation) of Mr. Ms. ____________________________________(name

of Life Insured), 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 or any of its authorized representative, 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 hereby also give consent to M/s. Birla Sun Life Insurance Co. Ltd. and /or its representative to obtain all medical/

hospital/ other records (including attested photocopies)/ information pertaining to the Medical treatment/ other

information of the deceased with any Hospital/ Clinic/ Physician etc without requiring my presence in person by

these authorities.

Yours faithfully,

_________________________________________________________

Name & Signature of Claimant

Birla Sun Life Insurance Company Limited 6th Floor, Claims Dept., G-Corp Tech Park, Kasarvadvali, Ghodbunder

Road, Thane (W)-400601. Email: BSLI.

, Tel. no. 022- 39961000

Regd. Office: One Indiabulls Centre, Tower 1, 16

Floor, Jupiter Mill Compound, 841, Senapati Bapat Marg,

Elphinstone Road, Mumbai – 400 013. Website:

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