DEATH CLAIM FORM (FORM- A)
For Branch Office use only
Branch Stamp
Date of claim receipt
Claim Submitted time
Before 3 pm
After 3 pm
Claim Submitted by
Nominee
Family Member
Agent
Others
Please accept our condolences for your untimely loss. We understand that this is a difficult time for you and it is our responsibility to offer you the best support in
this hour of need. This Death Claim Application form is designed to help you file your claim quickly and easily. Please return this form duly filled and signed
with appropriate documents and follow below instructions to help us settle your claim faster.
IMPORTANT INFORMATION
•
Claims under multiple policies may be registered by filling a single form & providing all applicable policy numbers.
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Claim is payable subject to the policy being in force on the date of event and fulfillment of all terms and conditions of the policy.
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If there is more than one claimant, separate forms need to be filled for each of the claimant.
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This form needs to be witnessed by any of the following (1) Max Life Agent (2) Sales Manager/ ADM/Office Head of Max Life (3) Block Development Officer (4) A bank
manager of a nationalized bank with rubber stamp (5) An officer of Max Life company not below the rank of a manager (6) A Gazetted Officer (7) A Head Master / Principal
of Govt. School (8) A Magistrate.
•
Please read the declarations carefully and sign the claim form in the same manner as you would normally sign your cheques. Your signature would be used to verify the
requests you give us in the future.
HOW TO COMPLETE YOUR FORM
All fields in the claim form should be filled by the claimant in BLOCK letters.
Section A
– This section seeks information about the claimant:
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Please make sure that your current address and mobile number is mentioned, as we would do all the claims communication on this address and mobile number only,
please provide your email-id in case you have one;
•
Please mention your complete bank account details; and
•
Please attach a NEFT Form attested by bank or a copy of cancelled cheque/bank account passbook to enable us to transfer the claim proceeds directly to your account
subject to the claim being payable as per the terms and conditions of the policy.
Section B
– This section seeks information about the Life Insured:
•
Please mention the cause, date and time of death of the Life Insured;
•
Please mention the names, addresses and telephone numbers of all doctors, hospitals or other medical sources who treated Life Insured during the last
illness/accident and over the last three (3) years. If necessary, please attach additional sheets; and
•
Please provide details of all life insurance policies of the Life Insured, with insurance companies other than Max Life Insurance.
Section C
– This section needs to
be filled only if different death benefit options are provided under the plans as mentioned in the form.
Section D
– This section can be used, if you want to
provide any additional information that is not covered in the claim form.
You need to submit the following documents along with this claim form (Please tick appropriate boxes to indicate documents
that have been submitted) – [Marked with * are mandatory documents]
1)
*Original / Attested Copy of Death Certificate issued by local authorities
2)
*Original Policy Document(s)
3)
*Attested copy of your identity proof (any one of the below- specifying your complete date of birth)
PAN Card Voter ID Card
Aadhaar Card Valid Driving License
Valid Passport Others (please specify)
4)
*Bank details (any one of the below)
Cancelled cheque with printed name and account details of Claimant
Copy of bank passbook / bank statement
NEFT form attested by bank
Additional documents in case of Suicide / Accident - (FIR and Post Mortem Report is mandatory)
*FIR Panchanama
*Post Mortem Report News paper cutting (if any)
Inquest report Final Police Investigation report
In case of Medical cause of death (Hospitalisation / Non-Hospitalisation) below documents are required
Medical cause of death certificate
Attendant Physician Statement (FORM “C” to be filled by last attending doctor)
All Medical records (diagnosis, treatment and discharge/death summary) – if applicable
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DEATH CLAIM FORM (FORM- A)
Max Life Policy Number (s)
Claim form is submitted through: Max Life Agent Max Life Office Bank Branch Others
Declaration: I/We the claimant(s) do solemnly declare that the below answers and statements are true in all respects and further
agree that the furnishing of this form, or any other form, or any other form supplemental thereto, to the company shall not constitute an
admission by the company that there was any insurance in force on the life in question or a waiver of any rights or defense.
Section A: Please tell us about yourself (claimant) - [Marked with * are mandatory fields]
*Name: *Date of Birth: *Gender M F
*Relationship with deceased life insured: Spouse Children Parents Others, Please Specify
*Current Correspondence Address:
State: Pin Code:
*Contact No.: Email ID:
PAN No.:
*Bank A/C No
.:
*Bank Branch Name & Address
: ______________________________________________________________________________________
MICR Code: *IFSC Code:
Section B: Please tell us about the deceased Life Insured - [Marked with * are mandatory fields]
*Name: *Age on Death: years
*Last Occupation: Last Employer details (If applicable)
*Date of death: *Time of death:
*Cause of Death: Medical Accident Suicide Murder
*Nature of illness/accident: *Date of diagnosis/accident:
*Place of death: Hospital / Clinic Residence Office Others (please specify)
*Please tell us details of the doctors who treated Life Insured during his/ her last illness/accident and/or during last 3 years:
Name of Doctor / Hospital
Contact details
Date of first consultation
Treatment taken
In case deceased life assured was insured with other life insurance companies, please provide details*:
Name of Company
Policy Number
Policy Amount
Policy Issue Date
Claim Status
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DEATH CLAIM FORM (FORM- A)
C: You need to complete this section only if you are claiming benefits under any of the following plans: (Selecting the
option does not confirm the admissibility of the claim.)
1) Max Life Guaranteed Income Plan:
Lump sum benefit
Regular Monthly Income
2) Max Life Guaranteed Monthly Income
Plan:
Lump sum benefit
Regular Monthly Income
3) Max Life Super Term Plan:
Immediate 100 % Payment
Immediate 50 % payment& 50 % as Monthly
Income
4) Max Life Forever Young Pension Plan:
Lump sum benefit
New Annuity Plan
New Pension Plan
5) Max Life Future Genius Education Plan
:
Lump sum benefit
Regular Monthly Income
D: Notes – Any additional information you would like to mention:
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Vernacular Declaration (If the claimant signs in vernacular or affixes thumb impression)
: Declaration from the Witness / Declarant to certify
that the contents of the form were explained to the claimant in vernacular and that he/she has affixed his/her signature /thumb impression hereto
after fully understanding the same.
NEFT Declaration: I authorize insurer for direct / electronic transfer of money in my above mentioned bank account. Max Life Insurance Co. Ltd. shall
not be held responsible in case of non credit of your bank account with/without assigning any reasons thereof or if the transaction is delayed or not effected
at all for reasons of incomplete/incorrect information. Further, Max Life Insurance Co. Ltd. reserves the right to use any alternative payout option
including demand draft/ payable at par cheque, if direct credit cannot be executed. Credit will be effected based solely on the claimant account
number information provided by the claimant and the claimant name particulars will not be used thereof.
I/We authorize Max Life to send all communications by E-mail/SMS or any other mode. I/We agree to receive regular reminders/ alerts from Max Life.
I understand that I have disclosed my personal information including Aadhaar number, voluntarily, with Max Life and I hereby provide consent to Max
Life to share my information with its authorized service providers/ other insurers/ reinsurer for the purpose of claims assessment/ investigation with
respect to this policy(s) mentioned in this form, as per the applicable regulatory framework.
Signature / Left thumb impression of Claimant Signature of Witness /Declarant
Name of Claimant: Name & address
:
Place: _
Date: Place:
Date:
DISCLAIMER
•
Submission of claim form with documents does not assure admission of the liability.
•
On assessment of documents submitted, Max Life reserves the right to call for additional documents.
•
Any person who knowingly files a claim containing false or misleading information , or who conceals information with intent to defraud or mislead
the Company or other person, may be guilty of felony or subject to other criminal and/or civil penalties as the case may be under the applicable
law(s). The company reserves the right to take appropriate action against the said person.
claims.support
@maxlifeinsurance.com
1860 120 5577
9 AM - 6 PM | Mon - Sat
Plot No. 90A, Sector 18,
Gurgaon, 122015, Haryana.
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DEATH CLAIM FORM (FORM- A)
Authorization (To be signed by the claimant)
In order to process your claim, additional documents may be required from different authorities. By signing this authorization, you give
Max Life Insurance Co. Ltd. and/ or its representatives the right to obtain the documents required on your behalf.
To,
Max Life Policy Number(s):
I, Mr./ Ms. (name),
(relation)
of Mr. /Ms. (name of the Life Insured) hereby give my consent to Max Life
Insurance Co. Ltd., and/or its representative to obtain Original or photocopies of employment / medical / govt. / pvt. hospital
records / other records / information necessary to process the claim
Yours faithfully,
Signature / Left thumb impression of Claimant Signature of Witness /Declarant
Name of Claimant: Name & address:
Place:
Date: Place:
Date:
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