Bharti AXA Life Insurance Company Limited

Unit No. 601 & 602, 6th floor, Raheja Titanium, Off Western Express Highway,
Goregaon (East), Mumbai - 400 063. www.bharti-axalife.com
Toll Free: 1800-102-4444

CLAIMANT’S STATEMENT
(To be completed by the Claimant)
No fees, commission or charges of whatever nature are payable to Agents or Employees of the Company in respect of this claim.
Details of the Life Insured
Policy No Name of deceased Life Insured Last Residential Address of the deceased Life Insured

Date and Place of Last Occupation of the

Age at death Cause of Death
Death deceased Life Insured

Details of the Claimant

Contact Number
Name and age Current Residential (Residence & Mobile) Residential Status of the Claimant (Check
of Claimant Address With e mail ID of the the relevant option)
claimant

Indian
Non-Resident Indian (‘NRI’)
Foreign national
If NRI or Foreign National, please provide
country of residence or nationality
…………………………………......................

Bank Account Details of Photo Identity Proof of Relationship of Claimant with deceased
Claimant Claimant life insured: (Check relevant option)
(Please enclose a copy of Bank (Please check submitted (Please enclose a copy of a relationship
Passbook / Bank Statement) document) proof)

Bank Name: Passport Son

PAN card Daughter
Voter’s ID Card Father
Driving License Mother
Account No.: Others (Please specify) Spouse
…………………..……………….. Others (Please specify)
……………………..…………..

Requirements to be submitted along with this form.

Please Tick whichever

Death Claims Requirement documents you have
submitted
1. Copy of Death Certificate duly attested by the Bharti AXA Life Insurance BIC / BH / COM /
CLM / RCOM / MOM / BSM / ABSM
2. Original Policy Kit
3. Claimant’s Statement
(Document No. F/CL/10/13/V6)
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 4. Copies of your Address Proof
5. Copies of your photo identity
6. Copies of your bank passbook / bank statement.
7. Copies of your proof of relationship with Life Insured
8. Employer’s Certificate
9. Last Attending Doctor’s Certificate
10. Hospital Treatment Certificate
11. Treating Doctor’s Certificate
12. Family Physician’s Certificate
13. Copies of Medical Records, Test Reports, Discharge summary, Admission records of
hospitals and indoor case papers

In case of an accidental / unnatural death, in addition to the above the copies of the
following documents duly attested by the Bharti AXA Life Insurance BIC / BH / COM / CLM
/ RCOM / MOM / BSM / ABSM need to be submitted:
1. First Information Report
2. Panchnama
3. Post Mortem Report and, if necessary, Chemical Analysis’s Report
4. Police Inquest Report

Note: The Company reserves the right to call for additional requirements, if needed

1. When did the health of the deceased Life Insured first become impaired? Please provide details.

…………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………

2. In case of an accidental death, please provide nature of accident (road, railway, etc.) and date of accident.

…………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………

3. Has there been a post mortem examination? (Check the relevant option)

Yes
No
If Yes, please submit attested copy of post mortem report

4. Has any First Information Report (‘FIR’) been lodged? (Check the relevant option)
Yes
No
If Yes, please submit attested copy of the FIR

5. Names and address of all physicians / hospitals who attended the deceased Life Insured during the last illness:
Name and Address of physician Date of Attendance Disease or Condition

(Document No. F/CL/10/13/V6)

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6. Names and address of all physicians / hospitals who attended the deceased Life Insured during the past five
years prior to his/her death:
Name and Address of physician Date of Attendance Disease or Condition

7. Have any immediate family members of the deceased Life Insured suffered from a similar related illness? If Yes,
please provide details
Relationship of the family member
Nature of Illness Date it was first diagnosed
with the deceased Life Insured

8. Was the deceased Life Insured covered by any other life insurance company/ ies or under Mediclaim? If Yes,
please provide details
Date on which the
Name of the Insurance Company Sum Assured Claim Status
policy was issued

Declaration and Authorization:

I/We ………………………………………………………………………… do hereby declare that all the statements and
answers to all questions given by me above are to the best of my knowledge and belief, correct, complete and true.
I/We authorize any doctor / hospital / laboratory / institution / past and present employer(s)/business associates/any
life and non-life insurance company/organization or the Life Insurance Association’s medical register to provide any
knowledge or information concerning the life insured’s health, habits or employment to the Company.

Signature of Claimant Date

Name of Witness Signature of Witness

(Document No. F/CL/10/13/V6)

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 Payout Options
Mode selected would be used by the company to make payout(s) to the Claimant.
Payout would be in accordance and subject to the terms and conditions of the policy.

Full Name of the Claimant:

Payment Mode: □ NEFT □ ECS (Select Bank) MICR Code* (Mandatory for ECS):

Bank Name: IFSC Code (Mandatory for NEFT):

Bank Account Number: Account Type: □Saving Account □Current Account

Bank Address (Including State, City, Pin code):
Telephone with STD code:

E- mail:

* 9 digit MICR code of the bank and branch appearing on the cheque issued by the bank. Submit a blank cancelled cheque along with the form.
(Kindly ensure that the first four digits of MICR code that you fill in are all not zero.)

Disclaimer: 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 condition 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 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.

Bank Account No:

I hereby take the sole responsibility for the correctness of my Bank Account number and other details of this form. I undertake that I will
not hold the company responsible in any manner for any transactions affected by the company due to incorrect Bank Account No. Or
these details stated by me.

Name and Signature of the Claimant:

Location: Date:

Contact Details:

(Document No. F/CL/10/13/V6)

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