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Tata AIA Life Insurance Company Limited

(hereinafter called “the Company”)
DEATH CLAIM INTIMATION - CUM - CLAIMANT’S STATEMENT
Guidelines / Notes:
1. Death benefit is payable subject to policy being inforce on date of death.
2. Only the person entitled to receive the policy monies under the Policy should fill & sign this form.
Please affix
3. Submission of this form should not to be construed as acceptance of claim. recent
4. Please submit the form & the requirements at the nearest Tata AIA Life branch office or the address given below; photograph
Tata AIA Life Insurance Company Limited, B- wing, 9th Floor, I-Think Techno Campus, Behind TCS, Pokhran Road No.2, Close to
Eastern Express Highway, Thane (West) Pin Code – 400 607.
5. Early and complete submission of requirements would enable the company to process the claim at the earliest
6. Claims under multiple policies may be reported by filling a single form & providing all relevant policy nos.
7. To be completed by claimant in BLOCK letters.

Policy Number(s):
1. Details of the Life Assured:
Full Name: Gender: Age at Death: D D M M Y Y Y Y

Address at the time of death:

Tel. No.:
City/ Town: Pin Code: State:

2. Details of the Claimant (person entitled to receive claim proceeds under the policy):
Full Name: Gender: Date of Birth: D D M M Y Y Y Y

Current Correspondence Address: Tel. No.:

City/ Town: Pin Code: State:

Residential Status: Resident Indian Non Resident Indian (NRI)
Pan Card No.
Place of Birth: Country of Birth:
If NRI, please state Country of Residence: Email address:
Relationship with the Life Assured:
Residence for tax purpose in jurisdiction(s) outside India: Yes / No (If ‘Yes’ then FATCA & CRS-Self Certification Form to be mandatorily completed)
Nature of title to the Policy monies: Policyowner Nominee Assignee Other
Please enclose a copy of Photo Identification : Passport Driving License Company ID card
proof (please tick whichever is applicable): Election card Credit Card with Photo PAN Card Bank Pass book with Photo Club card If Any
Other, please specify
Requirements submitted along with this form Please Tick (ü)
1. Original Policy Document
2. Copy of Death Certificate issued by Local Authority
3. Photo ID and date of birth proof of insured and claimant
4. Copy of Medico legal cause of Death Certificate
5. Medical Records (admission notes, discharge summary, test reports etc.)
6. Post Mortem Report (If applicable)
7. FIR/ Panchnama/ Inquest Report (If applicable)
8. Employer’s Certificate
9. Hospital Information sheet
10. Cancelled cheque for NEFT
11. Copy of Driving License (If applicable)
(applicable only if “Accidental Death Benefit Rider” is opted)
Note: The Company reserves the right to call for additional requirements, if needed

3a. Details of the Claim:

Date of Death: Cause of Death:

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3b. Other Details

Place of Death (specify the name and address of the hospital, wherever applicable):

Name & Address of the Doctor who declared the death:

City/ Town: Pin Code: Tel No:

Date of Post Mortem examination: Date & Time of cremation/ burial:
Name & Address of hospital where Post Mortem examination was done:

City/ Town: Pin Code: Tel No:

Name & Address of Police Station where FIR has been lodged:

City/ Town: Pin Code: Tel No:

What do you understand to be the circumstances of the Life Assured’s death?

4. Medical History of the Life Assured:

Nature of illness/ ailment:
Duration of the illness/ ailment (specify from – to dates):
Name & Address of the doctor/ hospital who diagnosed & treated the Life Assured:

City/ Town: Pin code: Tel No:

Name & Address of Life Assured's usual/ family doctor:

City/ Town: Pin code: Tel No:

5. Employment Details:
Employer’s/ business name:
Address:
City/ Town: Pin Code: Tel No:
Designation at work place/ business:
Exact nature of job/ business:
Date of last working day:
6. Particulars of other Life Insurance / Mediclaim policies held by the Life Assured:
Policy No. (1) (2) (3) (4)
Name of the Insurance company:
Commencement date:
Sum Assured:
Riders opted:
Status of the Claim:

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Declaration & Authorization

I hereby declare that the information given on this death claim application form is true and complete to the best of my knowledge and belief.
I hereby make a claim on Company by submitting this death claim application form and agree that the written statements of all the physicians who attended or treated the deceased (Insured) and all other
proofs and supporting documents associated with this death claim application form shall constitute and are hereby made part of this death claim application form. I further agree that the furnishing of this
death claim application form, or of any other forms supplemental hereto to the Company, shall not be deemed an acceptance of an existence of any assurance in force on the life in question, nor a waiver of any
of its rights of defenses.
I hereby irrevocably authorise any organisation, institution, or individual that has any record or knowledge of the Deceased ‘s (Insured’s) health and medical history or any treatment or advice and that has been
or may hereafter be consulted, other personal information or details of related accident/injury to disclose to Company such information. This authorisation shall bind my successors and assigns and remain
valid notwithstanding my death or incapacity in so far as legally possible. A photocopy of this authorisation shall be as valid as the original.
I hereby declare and agree that any personal information collected or held by the Company (whether contained in this application or otherwise obtained) is provided and may be held, used, and disclosed by the
Company to individuals/organisations associated with the Company or any selected third party (within or outside of India, including reinsurance and claims investigation companies and industry
associations/federations) for the purposes of processing this application.

Witness Signature Claimant Signature

Name of the Witness __________________________________ Name of Claimant ____________________________________

(in block letters, family name first) (in block letters, family name first)
Address of Witness: ___________________________________
________________________________________________
Designation: _______________________________________
Date: Date:
Note: - Witness should be a Notary/ Gazette Officer /Gram Panchayat Pradhan/Gram Panchayat Member/ Doctor/ Lawyer/ School Headmaster/Ward councilor/Block Development Officer/NGO/ Bank
Manager/ BOI/BOE/Zone claims person/ SEM or a person of local standing.

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Authorization
(To be signed by the claimant)

To,

Life Insurance Policy Number(s):___________________________

I, Mr./ Ms. __________________________________(name), ______________ (relation) of Mr./ Ms. __________________________name of the Life
Assured) hereby give my consent to “Tata AIA Life Insurance Company Ltd., and/ or its representative to obtain all employment/ medical/Govt. or Pvt. hospital
records/ other records (including photocopies)/ information pertaining to the treatment/ occupation of the deceased.

Yours faithfully,

Witness Signature Claimant Signature

Name of the Witness __________________________________ Name of Claimant ____________________________________

(in block letters, family name first) (in block letters, family name first)
Address of Witness: ___________________________________
________________________________________________
Designation: _______________________________________
Date: Date:

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Tata AIA Life Insurance Company Limited

(hereinafter called “the Company”)

ELECTRONIC PAYOUT METHODS

Please tick one of the options :

National Electronic Fund Transfer (NEFT) Electronic Clearing System (ECS)
If none of the above options are selected, the default option will be Cheque. Please attach a cancelled copy of your
cheque if any of the above payout option is selected.
Full Name of Account Holder F I R S T M I D D L E L A S T
Full Name of the Bank F I R S T M I D D L E L A S T
Branch
Account Type Current Savings Please select which ever is applicable
Bank Account No

MICR Code (Only mandatory for ECS mode) (9 digit code on your cheque next to cheque no.)

IFSC Code (11 digit IFSC Code) (You can get this code from your bank)

The payout mode selected in this form would be used by the Company to make all payout(s) to the Claimant. Payouts would be in accordance and subject to the terms and
conditions of the policy.
I declare and state that the Company shall not be responsible for non credit of my bank account for any reason whatsoever or if the credit is delayed. I also understand and
agree that the Company reserves the right to use any alternative payout option including a demand draft payable at par or cheque, in-spite of my opting for the electronic
payout method. I undertake to provide the IFSC code to the company. I understand that the IFSC code for RTGS and IFSC code for NEFT may be different.
I understand and agree that the submission of this Form does not mean or amount to the acceptance of the claim by the company.

Date:

Signature of Claimant Signature and stamp of branch manager

Tata AIA Life Insurance Company Limited (IRDAI Regn. No.110) CIN: U66010MH2000PLC128403. Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat
Marg, Lower Parel, Mumbai - 400013. Trade logo displayed above belongs to Tata Sons Ltd and AIA Group Ltd. and is used by Tata AIA Life Insurance Company Ltd under a license. For any information
including cancellation, claims and complaints, please contact our Insurance Advisor / Intermediary or visit Tata AIA Life’s nearest branch office or call 1-860-266-9966 (local charges apply) or write to
us at [email protected]. Visit us at: www.tataaia.com or SMS 'LIFE’ to 58888.
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