Group Insurance Rider Claim Form (Page 2 of 2) in pdf

Remarks _______________________________________________________________________________________________________

_______________________________________________________________________________________________________

DECLARATION AND AUTHORITY TO PAY CLAIM

I/We the undersigned, in my/our capacity as (designation)………………………………………………………………..and duly authorised to make this

declaration, hereby declare:

That the person whose resignation / retirement / death/Illness gave rise to this claim has in fact resigned / retired / died and was in fact a legitimate member

of the Plan on the date of resignation / retirement / death /Illness.

That he/she joined employment / the Group on (date) …………….. and he/she was actively at work / in Good Health on the date of commencement of

ii.

cover.

iii.

That in the event the claim is admitted, the payment of the proceeds due in respect of the above member in terms of the afore-mentioned Plan shall

represent the full and final discharge of Kotak Mahindra Old Mutual Life Insurance Ltd’s liability in respect of that member under the said Plan.

Signed at: ………………………………………………………………………. this………….day of…………………………. 20…..

Designation …………………………………..

OFFICIAL

COMPANY

Name …………………………………………

STAMP

Signature ……………………………………...

Please attach to this form Primary documentation required for Death /Illness claims:



Original death certificate issued by the Municipal Authority



Last attending doctor's certificate stating the exact cause of death



Proof of age (e.g. Birth Certificate, School leaving certificate etc.)



Proof of membership (e.g. Certified copy of the latest Pay slip, certified copy of membership card etc)



If death has occurred in a hospital, all case history papers.



If the death is due to an accident or any other unnatural cause, we require

A certified copy of the FIR filed with the Police authorities

A certified copy of the Post Mortem Report/Autopsy Report

A certified copy of the Driving License if death occurred while driving



Beneficiary nomination form if claim is payable to the beneficiary



Proof of relationship with member (for family benefit claims only)

(The above mentioned documents are indicative and additional documents may be called for where necessary)

FOR Kotak Mahindra Old Mutual Life Insurance Ltd. OFFICE USE ONLY

I confirm that I have checked the details on this form and have satisfied myself that they are correct.

Name …………………………………………………………

Designation …………………………………………………..

Signature …………………………………………………….

Group Insurance Rider Claim Form Page 2

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