Fillable Credit Life Death / Disability Claim Form (Credit Card) printable pdf download

CREDIT LIFE DEATH / DISABILITY

CLAIM FORM (CREDIT CARD)

American Life Insurance Company

MetLife Building, 18- 20 Motijheel C/A

BGL-

POLICY NO.:

P. O. Box 9, Dhaka- 1000, Bangladesh.

NAME OF INSURED ___________________________________________________________________________________

(Primary Cardholder)

CREDIT CARD NUMBER________________________________ CARD A/C NUMBER _____________________________

BE NEFICIARY’ S STATEMENT

Date of Birth of Insured

Place of Birt h

Occupation at time of Death /Disability

Date last worked full time (if applicable)

What is your relationship to the insured?

Family Contact Person

Address

Contact Number

PHYSICIAN’S STATEMENT (Must be filled by the Physician’s own handwriting)

Date of Death/ Disability

Place of Death/ Disability

Interval between onset of illness/injury and Death/ D isability

9 a. Disease or condition directly leading to Death / Disability: (This does not mean the mode of dying, such as Heart

Failure, Asthma etc. It means the disease, injury or complication which caused Death/ Disability.)

9 b. If Death/ Disability was due to accident, suicide of homicide, specify which and describe briefly:

10. Did the deceased / disabled person receive treatment from YOU or to best of your knowledge, from any other physician, or in

any Hospital or institution during the last 5 years? (If YES to either question, please mention the Name, Address, Dates, and

Nature of illness/injury)

Name, Address, Signature and Seal of Attending Physician

Name:

Address:

Signature & Seal

AUTHORIZATION

I hereby certify that the foregoing statements are full and true to the best of my knowledge and hereby authorize, on behalf of the

Cardholder, all physicians, hospitals, clinics, pharmacists, laboratories, employers and any institution or any other person who has

any record or information about the deceased/disabled Cardholder to provide American Life Insurance Company (MetLife) any

and all information with respect to medical history, consultation, prescription or treatments and copies of all hospital or medical

records. Any copy of this authorization shall be taken as the original copy

Policy holder Beneficiary

______________________

Authorized Signature ______________________ Date __________

Beneficiary

______________________________ __________

Signature _________ _____________ Date _________

Witness

_______________________ ____________ __________ Signature ______________________ Date _________

POLICYHOLDER’S STATEMENT

Notice is hereby given of the Death/Disability of (Name) _____________________________________________ of

(Address)_________________________________________________________________________________________ ____

a Cardholder of this Bank with Card Account N umber_______________________________ since _________________who

was enrolled into the Group Insurance Scheme on __________________. We hereby warrant that such insurance was in force

at the Date of Death/Disability and that the said Cardholder was in our list of Insured Cardholder dated _________________ for

BDT____________ ______________ (Last Statement Balance for which Premium was Paid) and also certify that the

Outstanding Balance, as per Policy Terms, is BDT___________________.

Date ___________ ________________ 20

_________

______________________________________

Authorized Signature and Official Seal

American Life Insurance Company is incorporated in the USA as a Limited Company

Credit Life Death / Disability Claim Form (Credit Card)

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