Customer Helpline No: 1860 266 7766

CLAIMANT STATEMENT FORM (DEATH CLAIMS)

• The Claimant statement form must be filled by the claimant / beneficiary under the policy or by the legally entitled person
• Send all required documents to "Claim Cell" address mentioned in the page below
DOCUMENTS TO BE SUBMITTED
Mandatory documents Additional documents for sum assured cases
1. Original policy certificate Natural death / Death due to illness
2. Copy of death certificate issued by local authority 1. Copy of medico legal cause of death
3. Claimant's current address proof 2. Medical records (Admission notes, Discharge / Death summary, Test reports, etc.)
4. Claimant's photo identity proof Accidental death
5. Cancelled cheque / Copy of bank passbook Copy of FIR, Panchnama, Inquest report, Postmortem report, Driving licence

1. POLICY DETAILS:
8 digit policy number(s):
(Please mention all policy numbers with ICICI Prudential Life Insurance Co. Ltd.)
2. CLAIMANT DETAILS (Current residential address should match with address proof provided):
Name: Relationship with life assured:
Date of birth: DD/MM/YYYY Address:

Pincode: Telephone with STD code:

Mobile number: Email ID:
3. DETAILS OF DECEASED LIFE ASSURED:
Name: Fathers Name:
Date of birth: DD/MM/YYYY Date of death: DD/MM/YYYY
Place of death: Hospital / Clinic Residence Office Others Please specify:
Age at death:

CAUSE OF DEATH / NATURE OF ILLNESS / HABIT (Please tick ü

/û
) Date of diagnosis of illness
£
Hypertension £
Diabetes £
Heart disease £
Liver disease £
Kidney disease £
Cancer
£
Smoking £
Alcohol £
Tobacco £
Drugs
£
Accidental £
Suicide £
Others
Any hospitalisation / Illness in last 5 yrs. £
Yes £
No Details
Name & Telephone number of the Doctor who declared death:
Name & Address of Police Station where FIR was lodged (if any):
4. TREATMENT / DIAGNOSIS OF ILLNESS:
Nature of the illness:
Date of diagnosis: DD/MM/YYYY Date of admission: DD/MM/YYYY Date of discharge: DD/MM/YYYY
Name of treating doctor / Hospital: Address:
Telephone with STD code:
5. EMPLOYMENT DETAILS:
Last employer's / Business name:
Designation: Last working date:
Address:
Telephone with STD code:
Comp/doc/June/2013/248

6. PARTICULARS OF OTHER LIFE INSURANCE / MEDICLAIM POLICIES HELD BY THE LIFE ASSURED
Name of the Company / TPA Policy number Sum assured

7. ARE YOU A POLITICALLY EXPOSED PERSON (CLAIMANT)? Yes No

Politically Exposed Persons (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign country, example, Heads of State or
of Governments, senior politicians, senior government / judicial / military officials, senior executives of state owned corporations, important political party officials, etc., including their family members and
close relatives.
Claim contact points

Claim Cell: ICICI Prudential Life Insurance Co. Ltd., 9th Floor, B wing, Office No. 906, BSEL Tech Park, Opp. Vashi Station, Sector 30, Vashi, Navi Mumbai - 400706.
24x7 Customer Helpline No.: 1860 266 7766 • Email us: lifeline@iciciprulife.com • Log on to our website: www.iciciprulife.com

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8. ELECTRONIC PAYOUT OPTION (Direct transfer of funds to your Bank Account) Please submit cancelled cheque / cheque copy along with this form
Name of account holder:
(as mentioned in Bank Account)

Mobile number: Bank name:

CBS
Branch name & address: PERSONAL BANKING : SAVING ACCOUNT DATE
PAY
OR BEARER
RUPEES
Bank account no.: Rs.
SBGEN A/c No. ANWB
005070123756

MICR code: Prabhadevi Branch

Ground Floor, Kala Academy, Ravindra Natya Mandir
9 digit code as appearing on the Cheque copy issued by bank. Prabhadevi Mumbai - 400 028
RTGS / NEFT IFSC Code : ICIC0000057

Please attach a copy of cancelled Cheque for verifying MICR code. ’338894 ’ 400229013 000000 ’ 31

IFSC code: Branch Address MICR Code IFSC Code

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
conditions of the policy. Further the Company reserves the right to use any alternative payout option including demand draft/payable at par cheque inspite of opting for electronic
payout method. Responsibility of providing IFSC code lies with the customer. Please note that IFSC code for RTGS & IFSC code for NEFT may be different. I will not hold ICICI
Prudential Life Insurance Company Ltd. responsible in cases of non-credit to my bank account or if the transaction is delayed or not effected at all for reasons of incomplete /
incorrect information.

x
Signature / Thumb impression of the claimant Place: Date: DD/MM/YYYY

9. ICICI BANK Account details, if any, held in the name of Life Assured* (This information will be passed onto ICICI Bank for closure formalities):
ICICI Bank account number:
AUTHORIZATION / DECLARATION
Insurance Policy Number (s):
I, Mr. / Ms. / Mrs. (name),
(relation) of Mr. / Ms. / Mrs. (name of the Life Assured), do hereby declare that the above statements
are true in each & every respect. I hereby give my consent to ICICI Prudential Life Insurance Co. Ltd. and its representatives to obtain information / documents (including photocopies)
from past and the present employer(s) / Business Associates / Medical Practitioners / Hospitals (Government / Private) / Birth and Death Registrar / Any life and non-life insurance
company and Life Insurance Association’s Medical Register. I hereby request the relevant authorities to release to ICICI Prudential Life Insurance Co. Ltd. and its representatives any
details regarding state of health, habits and occupation of the life assured within his/ her knowledge before or after the policy was issued and ICICI Prudential Life Insurance Co. Ltd. to
release to any Life and non-life insurance company / or Life Insurance Association’s Medical Register, such details and provide the record of employment / business or other details as
may be considered relevant.
In case where Sum Assured is zero / Investment plan / Paid-up policies, where the Policy document is not submitted to the Company and where the total payment is not more than ` 5
lakhs, 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.
Please note: Claim benefits under Pension Products will be paid in lump-sum unless requested for periodic pension.
Yours faithfully,

Signature / Thumb impression of the claimant / Nominee Name & signature of the witness

x Submit your identity & address proof Relation with claimant

Mobile number Mobile number
Place: Date: DD/MM/YYYY Place: Date: DD/MM/YYYY

FOR OFFICE USE ONLY (BRANCH OPERATIONS): Claim submitted time: Before 3 pm After 3 pm
Nominee name:
(Nominee name should match with name mentioned in policy certificate)

Nominee ID & address proof collected Y / N If N reason:

Policy status: STAMP
&
Claim submitted by Nominee Family member Advisor Other (Please specify) TIME

Name of the claims assessor contacted: Phone no.:

SPAARC call ID:
Please scan the documents in Omni docs under Claim service documents

*Please note the company is only facilitating the closure of the account and shall not be held responsible in case of any delay or failure on part of the bank to close the account. For any
clarification in this regards, you are requested to directly coordinate with the bank.

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 ACKNOWLEDGMENT SLIP
Customer Helpline No: 1860 266 7766 (DEATH CLAIMS)

Policy number(s)
Name of claimant
Branch name & code
Date DD/MM/YYYY Employee name & code
Documents Original policy certificate Claimant's photo identity proof Claimant's address proof STAMP
submitted: Cancelled cheque Copy of death certificate issued by local authority
Others

• Where sum assured is zero (Pension Plans) fund value as on date of intimation is payable
• The acknowledgment slip should not be construed as acceptance of claim. The Company reserves the right to call for additional documents / requirements

Claim contact points

Claim Cell: ICICI Prudential Life Insurance Co. Ltd., 9th Floor, B wing, Office No. 906, BSEL Tech Park, Opp. Vashi Station, Sector 30, Vashi, Navi Mumbai - 400706.
24x7 Customer Helpline No.: 1860 266 7766 • Email us: lifeline@iciciprulife.com • Log on to our website: www.iciciprulife.com