Annex - I

Claim Application Form for PLI/RPLI (Death Cases)

(Please fill in BLOCK Capitals)

Service Request No. :

(For Official Only)
1 Policy Details :

i Policy No. : ii Name of Insurant :

Date of Acceptance :
iii Sum Assured : iv
(dd/mm/yyyy)

Date of Survival Benefit Due : Date of Maturity :

v vi
(AEA Policy) (dd/mm/yyyy) (dd/mm/yyyyy)
Loan taken against policy : Yes No
vii
(if yes please attach Loan Repayment Receipt Book& fill column 2)
Date of Loan Repayment :
2. Loan Sanctioned Amount :
(dd/mm/yyyy)

3. Details of Death of Insurant:

Date of Death :
i ii Cause of Death :
(dd/mm/yyyy)

iii Place of Death (Full Address with Pin Code) :

4.(A) Details of Claimant-1:

Age of Claimant *:
i Name of Claimant : ii
(if Claimant is minor please fill column 5)

iii Relationship of Claimant with Insurant: iv Proof of Relationship ** :

v
Address:

District : State :

PIN Code : Mobile No :

Share of Claim
e-Mail ID :
amount (%) :

4.(B) Details of Claimant-2 (if Claimant is more than one):

Age of Claimant *:
i Name of Claimant: ii
(if Claimant is minor please fill column 5)

iii Relationship of Claimant with Insurant: iv Proof of Relationship ** :

v Address:

District : State :

PIN Code : Mobile No :

 Share of Claim
e-Mail ID :
amount (%) :

Details of Claimant-3 (if Claimant is more than

4.(C)
one):

Age of Claimant *:
i Name of Claimant : ii
(if Claimant is minor please fill column 5)

iii Relationship of Claimant with Insured : iv Proof of Relationship ** :

v Address:

District : State :

PIN Code : Mobile No :

Share of Claim
e-Mail ID :
amount (%) :

5. (A) To be filled If Claimant is a minor (A) if minor Claimant is more than one:

i Name of Guardian/ Appointee : ii Relationship with minor claimant :

iii Is Father of minor claimant deceased (Y/N): iv Is Mother of minor claimant deceased (Y/N):

5. (B) To be filled If Claimant is a minor (B) if minor Claimant is more than one:

i Name of Guardian/ Appointee : ii Relationship with minor claimant :

iii Is Father of minor claimant deceased (Y/N): iv Is Mother of minor claimant deceased (Y/N):

If you are not father or mother of the minor claimant, have you been appointed guardian of the minor claimant by nomination or

under any enactment in force in India? Please state and produce document in support of your claim
v
(Claimant A) _________________________________________________________________________________________

(Claimant B) _________________________________________________________________________________________

Does the minor claimant resides with you :

vi vii Is the minor maintained by you (Yes/No) :
(Yes/No)

6. Account Details (if payment desired through Bank Mandate)

Post Office Bank Account No. :

Name of Account Holder:

Name of Post Office/Bank: Branch:

IFSC code: Cancelled Cheque Enclosed (Y/N):

(*) Age of Claimant in completed years.

(**) Provide any valid document for proof of relationship between Insurant and Claimant.
Documents Enclosed: Yes/No/ NA(Not Applicable)

1. Original Policy Bond or Letter of Indemnity (Format at Annex III)

2. Self Attested copy of Death Certificate (issued by Local Administration/register of local board/village panchayat/Medical
Practitioner or Certificate of Doctor, who last attended the insurer clearly mentioning reason of death)

3. Self Attested copy of Succession Cert./Letter of Administration/Probate of Will, if nomination is not available

4. Self Attested copy of ID proof of the Claimant(s)

5. Self Attested copy of address proof of the Claimant(s)

6. Self Attested copy of FIR (in case of unnatural death of Insurant)

7. Self Attested Post-mortem report (in case of unnatural death of Insurant)

8. Cancelled Cheque of Claimant(s)’s Bank Account(s) for Bank Mandate

9. Documents of Credit or Premium Receipt Book (D.O.C. if Pay policy or Premium Receipt Book if Cash Policy and all the paid

premium not updated on McCamish Software)

10. Loan Receipt Book (if Loan taken on Policy)

11. Indemnity Bond (in case of Unantural death)

12. Any other document(s), pls specify ………………………………………………………………………………………………

Date: ______________

Signature/Thumbprint of Claimant/Guardian of Claimant

In case Claimant/Guardian of Claimant is illiterate, there should be two literate witnesses-

Witness Name & Address Signature

Witness 1
Witness 2

----------------------------------------------------------------------------------------------------------------------------------------------------------------------

For Official Use

Certified that I have checked all the documents enclosed and compared with the original document produced by the claimant and
verified the averments made in the claim form based on these documents and found no discrepancies.

Date:- Signature of BPM/SPM/PM/ CPC in-Charge

Name :
Designation:
Office Stamp:
 Acknowledgement Slip
(To be filled by BPM/SPM/Post Master/CPC in-charge and Handed Over to Claimant)

Claim Application for Policy No.____________________received on ___________with Service Request No.__________________and

following documents are received from the Claimant:

Documents Received: Yes/No/ NA (Not Applicable)

1. Original Policy Bond or Letter of Indemnity

2. Self Attested copy of Death Certificate (issued by Local Administration/register of local board/village panchayat/Medical
Practitioner or Certificate from Doctor who last attended the insurer clearly mentioning reason of death)

3. Self Attested copy of Succession Cert./Letter of Administration/Probate of Will if nomination is not available

4. Self Attested copy of ID proof of the Claimant(s)

5. Self Attested copy of address proof of the Claimant(s)

6. Self Attested copy of FIR (in case of unnatural death of Insurant)

7. Self Attested Post-mortem report (in case of unnatural death of Insurant)

8. Cancelled Cheque of Claimant(s)’s Bank Account(s) for Bank Mandate

9. Documents of Credit or Premium Receipt Book (D.O.C. if Pay policy or Premium Receipt Book if Cash Policy and all the paid

premium not updated on McCamish Software)

10. Loan Receipt Book (if Loan taken on Policy)

11. Indemnity Bond (in case of Unantural death)

12. Any other document(s), pls specify ………………………………………………………………………………………………

Date:- Signature of BPM/SPM/PM/ CPC in-Charge

Name :
Designation:
Office Stamp: