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CLAIMANT STATEMENT FORM (DEATH CLAIM):

FORM (A-1)

WITHOUT PREJUDICE
• The form needs to be completed by the claimant under the policy or by the legally entitled person
• Please ensure all questions are answered. Ensure use of “Not Applicable” (N/A) instead of leaving it blank
• Claim proceeds are payable as per terms & conditions mentioned in the policy document and subject to the policy being inforce as on the date of
event/death
• Acceptance of forms does not amount to admission of the liability by the Company
• Submission of proof of death is mandatory along with this form

CLAIMS GUARANTEE
WE SHALL TAKE ONLY 24 HOURS FOR THE SETTLEMENT OF BONA-FIDE CLAIMS AFTER SUBMISSION OF ALL REQUIRED
DOCUMENTS AND INFORMATION

CLAIM DOCUMENTS TO BE SUBMITTED


Documents (as per the cause of death)
Basic documents required
Death due to Illness Death in case of Accident
1. Original Policy Document/(s) Treating Doctor’s Certificate in prescribed Copy of the First Information Report (FIR) and/
2. Copy of Death Certificate format or Panchnama/Police Complaint
3. Copy of Cremation certificate Hospital Certificate in prescribed format if the Copy of the Post Mortem Report (PMR)/
4. Personalised cancelled cheque of Insured was hospitalized at the time of death Autopsy / Viscera report.
beneficiary
Copy of Medical records (Admission notes, Copy of the Final Police Investigation Report
5. Claimant Photo Identity and Address Proof
Discharge/ Death Summary, Test reports etc.) (FPIR)/Chargesheet.
(copy of passport, PAN card, Voter identity
card, Aadhar (UID) card, driving license) Employer certificate in prescribed format (if the Insured was in service)
Past hospital/treatment or prescription / Copy of Newspaper Article
pathological records of the Insured
On submission and assessment of the above documents, Edelweiss Tokio Life may require additional documents as deemed fit to arrive at the
final claims decision.

Policy No.:

Particulars Details of the Life Assured Details of the claimant


Name Mr./Mrs./Master/Ms.___________________________ Mr./Mrs./Master/Ms.___________________________
_____________________________________________ _____________________________________________
Address _____________________________________________ _____________________________________________
_____________________________________________ _____________________________________________
_____________________________________________ _____________________________________________
_____________________________________________ _____________________________________________
Tel. no.:
Date of death D D M M Y Y Y Y NA
Cause of death NA
Age at the time of death _____________ years NA
Place of death _____________________________________________ NA
Relationship with NA
Life Assured _____________________________________________
In what capacity NA Appointee Nominee
do you claim Assignee Others
If Claim is for an ANNUITY NA Lumpsum
or PENSION Product,
Please tick the appropriate Annuity
option/preference for
payment of benefits*
*Subject to applicable Terms
& Condition of the Policy
Page 1

Insurance se badhkar hai aapki zaroorat


Details of the claim
Name & address of the doctor who declared the death _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Date & time of cremation D D M M Y Y Y Y Time: _______________
Location of cremation
Date of post mortem examination D D M M Y Y Y Y
Name Address and contact no. of the hospital,
where the Post-mortem examination was carried out
In case of death due to accident, answer the following:
• Name & address of the police station where FIR was _______________________________________________________________
lodged _______________________________________________________________
• Date & Time of accident D D M M Y Y Y Y

• Place of accident _______________________________________________________________


• Was the Life Assured driving at the time of accident Yes No

Previous Health/ Habit details of Life Assured

Nature of Illness / Habit Kindly Tick the applicable response Duration of Illness If Yes, please provide details of
frequency and Quantity consumed
Hypertension Y N NA
Diabetes Y N NA
Heart disease Y N NA
Kidney disease Y N NA
Liver disease Y N NA
Cancer Y N NA
Any other ailments / disorder/ surgery/
hospitalisation in last 5 yrs Y N NA
Any habits like smoking/ alcohol/
tobacco/ drugs (Please select) Y N

Details of the Illness

Nature of the illness ______________________________________


Date of diagnosis D D M M Y Y Y Y

Treatment details ________________________________________________________


________________________________________________________
Hospitalization details • Name of the Hospital: __________________________________
• Date of Admission: D D M M Y Y Y Y

• Date of Discharge / Death: D D M M Y Y Y Y

(Kindly submit the copy of the Discharge Summary or Death Summary


along with this form)
Duration of illness related to current illness ____________________________________________
Details of hospitalisation expenses and mode of payment
Details of amount claimed under Mediclaim/health Name of the Sum Amount of Date of
insurance policy during last five years Insurer Assured claim received claim

Page 2
Names & Address of physician/hospitals attended the deceased within the last 5 years preceding death

Name of the Physician Address Date of First Nature and Details


and/or Hospital Visit/Treatment of Disease/ Illness

Other details of the Life Assured

Employment details
Last Employer’s / Business Name: _________________________________________________________

Address _________________________________________________________
_________________________________________________________
Designation at work place/business: _________________________________________________________
Last working date: D D M M Y Y Y Y

Annual income _________________________________________________________


Nature of Job/ Business _________________________________________________________
Family Physician details
Name of the doctor _________________________________________________________
Address & Tel. No. _________________________________________________________
_________________________________________________________
Since when has been the Life Assured taking treatment from the doctor _________________________________________________________
Name the illness for which treatment was taken _________________________________________________________
Particulars of other Life Insurance / Mediclaim policies held by the Life Assured

Name of the Insurer Policy No. Risk Commencement Status of Sum Assured Claim Raised Status of Amount
Date the Policy Yes/No Claim Claimed

Electronic Payout option (Direct transfer of funds in your bank A/c)

1. Name of the Bank A/c holder: _________________________________________________________________________________________


2. Bank Name: _______________________________________________________ Branch Name: __________________________________
3. A/c No.: ____________________________________
4. A/c Type: Saving Current NRI NRO
5. IFSC code: _____________________________________________ MICR Code: _____________________________________________
Personalised cancelled cheque required along with this form
Payouts would be in accordance and subject to the terms and conditions of the policy. Further, the company reserves the right to use any alternative
payout option including demand draft/payable at par cheque in spite of opting for Electronic payout method. I will not hold Edelweiss Tokio Life
Insurance Company Ltd. responsible in case of non-credit to my bank account or if the transaction is delayed or not effected at all for reasons of
incomplete/ incorrect information.

Signature / Thumb impression of the claimant: _________________________________


Date: D D M M Y Y Y Y
Page 3
I, Mr. / Ms. / Mrs. _________________________________________________________________ (name), ________________________ (relation) of
Mr. / Ms. / Mrs. _________________________________________________________________ (name of the Life Assured), do hereby declare and
confirm that I am the rightful claimant of the deceased person and the above statements are true and complete in each & every respect.
In case where the Policy document is not submitted to the Company, I hereby agree to indemnify the Company against all liabilities that the Company
may incur on account of any claim being made by any other person on the basis of possession of the Policy document or otherwise.
Certified that the content of this form were explained to the person declaring the above in vernacular and he/she has affixed is /her signature / thumb
impression hereto after fully understanding the same.
Yours Faithfully,

Signature / Thumb impression of the claimant Name & signature of the witness
Name: ___________________________________________________

Signature: ________________________________________________
Relation with the claimant: __________________________________
Telephone with STD code: ___________________________________ Telephone with STD code: ___________________________________
Place: ____________________________________ Place: ____________________________________
Date: _____________________________________ Date: _____________________________________

Page 4
AUTHORISATION
(To be filled and signed by the Claimant)
Policy No (s):_________________________________________
I, Mr. / Ms. / Mrs. _________________________________________________________________ (name), ________________________ (relation) of
Mr. / Ms. / Mrs. _________________________________________________________________ (name of the Life Assured), in order to enable the
company to assess the claim under this policy, I hereby authorize the Edelweiss Tokio Life to procure documents/details from:
• Past and present employer (s) or business associates
• Medical practitioner/ Hospitals (Govt/ Pvt.)
• Diagnostic centres wherein the life insured underwent personal / official / insurance related medical tests
• Birth and Death Registrar, Government Agencies including Police Authorities
• Any life and non life insurance company
And hereby give my consent to the above authorities to release to the Company, such details/documents which may be required during the assessment
of the claim. A photocopy of this authorization shall be considered as effective and valid as the Original.

Yours Faithfully,

Name of the Claimant: _______________________________________

Signature / Thumb impression of the claimant


Pan No.: __________________________________________________
Place: _______________________

Aadhar Card No.: ____________________________________________


Date: _______________________