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
D
D
M
M
Y
Y
Y
Y
1.
Date of Birth of Insured
2.
Place of Birt h
3.
Occupation at time of Death /Disability
4.
Date last worked full time (if applicable)
5.
What is your relationship to the insured?
6.
Family Contact Person
7.
Address
Contact Number
PHYSICIAN’S STATEMENT (Must be filled by the Physician’s own handwriting)
D
D
M
M
Y
Y
Y
Y
6.
Date of Death/ Disability
7.
Place of Death/ Disability
8.
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