Claim Form for Credit Life

WITHOUT PREJUDICE /

Page 1 of 9

CREDIT LIFE CLAIM FORM

(RINN Raksha, Dhanraksha, Super Suraksha)

CLAIMANT’S STATEMENT - DEATH CLAIM

-

Please submit this form along with the requirements mentioned below at the nearest branch

Documents to be submitted

Non Accidental Death

Accidental Death

Required

Submitted

Required

Submitted

Original Policy Document Yes

Yes

Original Death Certificate issued by Local Authority

Yes

Claimant’s Current Address, ID proof, Bank Pass Book/Bank Stmt/Crossed

Cheque

/ /

Yes

Copy of Medico Legal Cause of Death Certificate

Yes

Medical Records( Admission Notes, Discharge/Death Summary, Test Reports,

etc)

(

, / , ,

)

Yes

Copy of Post Mortem /Chemical Analysis Report

/

No

Yes

Copy of FIR/Panchanama Report/Inquest Report/ Police Final

Report/Magistrate’s Verdict

/ / /

No

Yes

Others (Please mention…………………………..)

( …………………………..)

Please submit the relevant supporting documents for faster processing of claim. The company reserves the right to call for additional

documents/requirements

/

Signature of the claimant /

_________________________

(a) Form to be filled in English/Hindi only

(

) /

(b) Kindly fill up the claim application form complete in all respects and accompanied by relevant documents, original or attested photocopy.

(c) Kindly be legible in filling up the application form and ensure all information is declared correctly and clearly. DO NOT leave any column

blank

Date & Time Stamp

(Office use only)

(

)

SBI Life Insurance Company Limited | Registered and Corporate Ofﬁce : Natraj, M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai - 400 069. Tel.: (022) 61910000.

Central Processing Center : 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector-40, Seawoods, Nerul Node, Navi Mumbai - 400 706. Tel.: (022) 66456000.

IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 267 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in, E-mail: info@sbilife.co.in

SBIL/CLM/Cr life DTH/Ver 2.03/06-19

Deceased

Life Assured photo

Claimant’s photo

(Signed Across)

(

)

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Page 2 of 9

PARTICULARS OF INSURED: :

Policy No (s):

:

Loan Account Number (Old & New):

Date of Birth

Gender: : Male Female

Deceased Name in Full: :

Occupation / Main Duties: / :

Marital Status at time of death: :

Single Married

Divorced Widowed

Residential Address :

:

Telephone Number

:

Mobile Number

:

DETAILS OF DEATH:

Date of Death :

Time of Death :

Place of death (State location of death e.g. hospital/institute/home – State

name of location & address) :

/ /

Date and Time of Cremation/ burial : /

Cause of Death

Copies of discharge/ death summary enclosed (YES / NO)

/ /

If NO – Please provide the reason

_______________________________________________________________________________

IF THE DEATH IS DUE TO AN ACCIDENT, PLEASE PROVIDE THE FOLLOWING

:

Date of accident :

Time of accident :

Name :

Address :

Telephone no. of the Police station where F.I.R. has been lodged

Name, address and telephone no. of hospital where post mortem examination

has been performed

Date of post mortem examination

Signature of the claimant /

_________________________

SBI Life Insurance Company Limited | Registered and Corporate Ofﬁce : Natraj, M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai - 400 069. Tel.: (022) 61910000.

Central Processing Center : 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector-40, Seawoods, Nerul Node, Navi Mumbai - 400 706. Tel.: (022) 66456000.

IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 267 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in, E-mail: info@sbilife.co.in

SBIL/CLM/Cr life DTH/Ver 2.03/06-19

Aadhar card No: (copy enclosed)

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Page 3 of 9

IF THE DEATH WAS DUE TO CAUSES OTHER THAN ACCIDENT, PLEASE PROVIDE THE FOLLOWING:

:

Nature of illness/ailment /

Duration of illness/ailment. / From : : To : :

Name, address and telephone no. of the Doctor/hospital who diagnosed and

treated the Life Assured.

/

Name, address & telephone no. of the Life Assureds’ usual/family Doctor

/

How Long has deceased been under treatment?

?

If the Post Mortem was carried out, provide the Date of Post Mortem

History of previous ailments, if any, and the treatment details thereof - _______________________________________________________

(Please Attach Copies of Past Treatment papers)

Employment Details – To be filled if the Life Assured was in Service anytime during the term of the policy

(Kindly submit the Employers Certificate with copies of Medical Certificates submitted for Leave availed on Medical Grounds)

:

Name of Company

Policy No.

Commencement

date

Sum Assured

Have you received the claim

amount

Note: You may use a separate sheet if the space provided herein above is not sufficient

:

Signature of Claimant/

_________________________

Employers Name:

Address :

Telephone No of Employer

Designation at work place/business /

Nature of Employment: Manual /Skilled /Unskilled /Technical /Clerical /

Supervisory/ Managerial / Other.

: / /

/ / / /

P.F. No. / Employee No /

/

SBI Life Insurance Company Limited | Registered and Corporate Ofﬁce : Natraj, M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai - 400 069. Tel.: (022) 61910000.

Central Processing Center : 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector-40, Seawoods, Nerul Node, Navi Mumbai - 400 706. Tel.: (022) 66456000.

IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 267 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in, E-mail: info@sbilife.co.in

SBIL/CLM/Cr life DTH/Ver 2.03/06-19

Details of Other Policies (Individual/Group Credit life/Group policy/Group Term Insurance) held by the deceased

WITHOUT PREJUDICE /

CLAIMANT(S) Details /

Claimant Name in Full

Address of the Claimant

(Please attach any one of these documents as Proof

of Residence)

Telephone No. :

Email :

Relationship with the Life Assured :

Date of Birth :

Please enclose a copy of Claimant’s Photo

Identification Proof

Occupation

Service Business Housewife Self Employed Others

If Others(Please specify) ________________________

Nature of title to the policy monies

Proposer/ Nominee/ Assignee/ Others

/ / /

Mobile No. :

BANK DETAILS OF THE CLAIMANTS (Please enclose a copy of Bank Pass Book)

Bank

mber

IFSC

mber

Name of

Branch Code Nu

IFSC Code No

Account Nu

Address of bank

Signature of Claimant/

__________________________

Aadhar card No: (copy enclosed)

SBIL/CLM/Cr life DTH/Ver 2.03/06-19

Page 4 of 9

SBI Life Insurance Company Limited | Registered and Corporate Ofﬁce : Natraj, M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai - 400 069. Tel.: (022) 61910000.

Central Processing Center : 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector-40, Seawoods, Nerul Node, Navi Mumbai - 400 706. Tel.: (022) 66456000.

IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 267 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in, E-mail: info@sbilife.co.in

WITHOUT PREJUDICE /

Page 5 of 9

CLAIMANT’s DECLARATION/

I _____________________________________________________________________ do hereby declare and confirm that I am

the rightful Claimant of the deceased person and the statements made herein above are true and complete in each and every

respect.

I hereby authorize any medical practitioner or hospital or nursing home or medical clinic who or which has attended upon or

examined or treated Life Insured for any ailment or illness to divulge any knowledge or information regarding Life Insured's state

of health which he / they may have acquired before or after the issuance of the policy, to SBI Life Insurance Co Ltd, any of its

offices, or Authorized Representatives, Court of law, or any grievance Redressal forum. I hereby confirm that this authorization is

irrevocable and is valid notwithsta

nding any law, custom or usage for the time being in force prohibiting any physician or hospital

from divulging any knowledge or information, acquired by him/ them in attending upon or examining a person on the ground of

secrecy.

/

Further, I hereby authorize any insurance company, government organization, employer, other organization, institution or person

to release to SBI Life Insurance Co Ltd or its duly authorized representatives any record or knowledge about deceased. I hereby

confirm that such information shall without limitation include information about deceased's health (including any information

relating to the use of drugs or alcohol, AIDS, or mental and physical history, condition, advice or treatment), earnings or other

insurance benefits, including any accounting information of the Life Insured's account.

/

I hereby declare that I am entitled to make the above authorizations. I also agree to render help to SBI Life Insurance Co Ltd or its

duly authorized representatives to gather the said information or any information that may help the company to assess this claim

and to use the information in whatever manner as may be deemed to be fit to assess this claim further.

SBI Life Insurance Company Limited | Registered and Corporate Ofﬁce : Natraj, M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai - 400 069. Tel.: (022) 61910000.

Central Processing Center : 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector-40, Seawoods, Nerul Node, Navi Mumbai - 400 706. Tel.: (022) 66456000.

IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 267 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in, E-mail: info@sbilife.co.in

SBIL/CLM/Cr life DTH/Ver 2.03/06-19

WITHOUT PREJUDICE /

Page 6 of 9

Authorization /

I hereby authorize SBI Life Insurance Company to make the Claim payment under above Certificate of Insurance (COI) Number as opted by me

under Serial Number 1 or 2 below:

1. Make the Claim payment by Cheque in favor of me.

2. Make the claim payment by Electronic Mode (EFT) and credit to my Savings bank Account Number-------------------------------

maintained with State Bank of India / ABS, Branch Name ----------------------------------

I hereby authorize SBILife to send the claim cheque as opted above to the State Bank India / Associate Bank, Branch Name ------------------------

to hand over to me for administrative convenience

1.

2.

Name in Block Letters: __________________________________________

Name of Witness /

Signature/

Signature/ Thumb Impression of the claimant:

Address /

_____________________________

Tel No/Mob No /

/ Place ( :_______________________Date ( :______________________

VERNACULAR DECLARATION /

:

(The above Declaration is to be given if claim form is signed in vernacular or if the claimant has used thumb impression instead of signature.)

I have explained the contents of this claim form to the claimant in ______________________________ __________________ (language) and ensured that the

contents have been fully understood by him/her. I have accurately recorded the claimant’s responses to the information sought in the claim form. I have read out

the responses to the claimant and he/she has confirmed that they are correct and affixed his/her thumb impression after fully understanding

the same.

Name of the Declarant: ________________________________________________________________________________

Address: ______________________________________________________________________________________________________________________ ____

Signature of the Declarant:

Place /

: ________________________________________________ Date / : __________________________________

P.S. - In Case of any dispute, the English version shall be Valid /

:

This printed form is issued on receipt of notice of death claim

To be completed by the nominee(s) or trustee(s) or assignee(s)

Acceptance of forms does not amount to admission of claim. This form is issued only for the limited purpose of assessment of claim about its

admissibility or otherwise

Any one of the following must be a Witness /Declarant in this statement: / /

Agent of SBI Life Insurance Co. Ltd. Unit Manager of SBI Life Insurance Co Ltd Advocate Bank Manager Magistrate

Block Development Officer Commissioner of Oaths Gazetted officer President of Panchayat Head postmaster Head master of School

SBI Life Insurance Company Limited | Registered and Corporate Ofﬁce : Natraj, M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai - 400 069. Tel.: (022) 61910000.

Central Processing Center : 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector-40, Seawoods, Nerul Node, Navi Mumbai - 400 706. Tel.: (022) 66456000.

IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 267 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in, E-mail: info@sbilife.co.in

SBIL/CLM/Cr life DTH/Ver 2.03/06-19

WITHOUT PREJUDICE /

Page 7 of 9

Authorization

(To be signed by the claimant)

To,

________________________________

I, Mr. /Ms. ______________________________________________ (Name), ________________

/

(Relation) of Mr. /Ms. __________________________________________ (name of the Deceased Life

/

Assured) hereby give my consent to SBI Life Insurance Co. Ltd., and/or its representative

to obtain (including photocopies) all the employment/medical/hospital records/other

/ / / / /

Records/information pertaining to the treatment of Late Mr. /Ms ________________________

Yours faithfully,

Signature of the claimant

Name of the claimant: ____________________________

Policy No. _________________________ Date: _______________

SBI Life Insurance Company Limited | Registered and Corporate Ofﬁce : Natraj, M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai - 400 069. Tel.: (022) 61910000.

Central Processing Center : 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector-40, Seawoods, Nerul Node, Navi Mumbai - 400 706. Tel.: (022) 66456000.

IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 267 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in, E-mail: info@sbilife.co.in

SBIL/CLM/Cr life DTH/Ver 2.03/06-19

WITHOUT PREJUDICE /

Page 8 of 9

Direct Credit Mandate /

I/We _________________________________ (Name of Policyholder/Nominee/Assignee/Trustee) hereby authorize SBI Life Insurance Co. Ltd.

to directly credit the claim proceeds of Rs. __________________ to my Bank Account, as per details given below:

/ / /

Account No

_________________________________

Bank Name

________________________________

Type of Account Savings Bank Current

Overdraft Cash Credit NRI/NRE#

Branch Name ________________________________ IFSC Code ______________________________

IFSC

Name of the Accountholder _________________________________ Mobile Number ___________________________

Mobile

e-Mail ID _________________________________@____________________

I agree that in case of any failure of Direct Credit, for any reason whatsoever, SBIL shall not be responsible. I also agree that SBIL shall

not be responsible/liable for any losses that may arise due to incorrect bank account details provided herein above.

/

Signature/ Thumb Impression of the Policyholder/Nominee/Assignee/Trustee

/ /

Policy Number/ ______________________________________ Date/ :_____________________________

VERNACULAR DECLARATION /

:

(The above Declaration is to be given if the above Mandate is signed in vernacular or if the claimant has used thumb impression instead of signature.)

I have explained the contents of this claim form to the claimant in ______________________________ __________________ (language ) and

ensured that the contents have been fully understood by him/her. I have accurately recorded the claimant’s responses to the information sought

in the claim form. I have read out the responses to the claimant and he/she has confirmed that they are correct and affixed his/her thumb

impression after fully understanding the same.

Name of the Declarant: ______________________________________________________________________________________

Address:__________________________________________________________________________________________________

Signature of the Declarant:

Place /

: ________________________________________________ Date / : __________________________________

# - For NRE account, letter from the bank is required for the direct credit of the claim amount.

Any one of the following is applicable

Attach pre-printed (Name) cancelled cheque

/

OR /

Self Attested Copy of Bank Passbook/

Statement/

/

SBI Life Insurance Company Limited | Registered and Corporate Ofﬁce : Natraj, M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai - 400 069. Tel.: (022) 61910000.

Central Processing Center : 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector-40, Seawoods, Nerul Node, Navi Mumbai - 400 706. Tel.: (022) 66456000.

IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 267 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in, E-mail: info@sbilife.co.in

SBIL/CLM/Cr life DTH/Ver 2.03/06-19

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Page 9 of 9

*Disclaimer

- Please note that the direct transfer of the Claim proceeds to bank account to be made only if

otherwise possible and allowed by banks as per banking regulations, Direct Credit will be possible only if either a

cancelled pre-printed cheque leaf is attached or above stated account details are attested by branch manager of the

bank where the bank account is being maintained. SBI life will not be responsible and liable for any losses occurring

due to incorrect account details provided by No minee/assignee/trustee.

-

/ /

Any one of the following must be a Witness /Declarant in this statement: / /

Agent of SBI Life Insurance Co. Ltd. Unit Manager of SBI Life Insurance Co Ltd Advocate Bank Manager Magistrate

Block Development Officer Commissioner of Oaths Gazetted officer President of Panchayat Head postmaster Head master of School

SBI Life Insurance Company Limited | Registered and Corporate Ofﬁce : Natraj, M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai - 400 069. Tel.: (022) 61910000.

Central Processing Center : 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector-40, Seawoods, Nerul Node, Navi Mumbai - 400 706. Tel.: (022) 66456000.

IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 267 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in, E-mail: info@sbilife.co.in