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Claim Intimation Form 2018

This document is a claim intimation form for personal accident or air accident insurance on SBI salary package account holders. It requests information such as the name, age, and address of the insured; details of the accident and death; bank branch details; salary package account number and type; and nominee details if available. The claimant must submit this form within 90 days of the account holder's death to claim insurance benefits under the group personal accident policy with IFFCO Tokio General Insurance for SBI salary package account holders.

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Randy Orton
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101 views2 pages

Claim Intimation Form 2018

This document is a claim intimation form for personal accident or air accident insurance on SBI salary package account holders. It requests information such as the name, age, and address of the insured; details of the accident and death; bank branch details; salary package account number and type; and nominee details if available. The claimant must submit this form within 90 days of the account holder's death to claim insurance benefits under the group personal accident policy with IFFCO Tokio General Insurance for SBI salary package account holders.

Uploaded by

Randy Orton
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Annexure 4

IFFCO TOKIO General Insurance Company Limited


AFL House, 2nd Floor, Lok Bharti Complex, Marol Maroshi Road,
Andheri (E), Mumbai – 400 059 (Maharashtra)
Email Id: sbigpa@iffcotokio.co.in

GROUP PERSONAL ACCIDENT/ AIR ACCIDENT CLAIM INTIMATION FORM TO BE SUBMITTED


FOR CLAIMING PERSONAL ACCIDENT INSURANCE (DEATH) / AIR ACCIDENT INSURANCE COVER
ON SALARY PACKAGE ACCOUNT HOLDERS OF SBI

Issuance of this format for intimation of a claim is not to be taken as an admission of liability.
(To be submitted to IFFCO Tokio General Insurance Co. Ltd. (ITGI) within 90 days after date of death of Salary
Package Account holder)

Policy State Bank of India – Salary Account Fax No. : 022 – 29203580
Holders Tollfree Phone No. : 1800 103 5499

Policy No. 51964755 for Policy Period 04/01/2018 to 03/01/2019

1 Name of Salary Account holder

Address in full
2

3 Age (in years)

a) Date of Accident

b)Time of Accident

4 c) Place of Accident

d)Details of Accident

e) Date of Death
a) Name of the Bank Branch
where the Salary Package
Account is maintained
b) Branch Code of the Bank
Branch where the Salary
5
Package Account is maintained
c) Postal Address of Bank
Branch to which
correspondence can be
exchanged by FGIICL
6 Salary Package Account No
# CSP/DSP/PMSP/ICGSP/SGSP/CGSP/PSP/RSP/SUSP
7 Type of Salary Package Account
@ Silver/ Gold/ Diamond/ Platinum
8 Variant of Salary Package A/C :
@ Army / Air Force / Navy / Indian Coast Guard/ Assam Rifle
Name of the organization in
9 / Rashtriya Rifle / BRO (GREF) / BSF / CRPF / CISF / ITBP /
case of DSP / PMSP / ICGSP
SSB / NSG
Personnel / Force number in
10
case of DSP / PMSP / ICGSP
Name of Nominee in the salary
11
package account [If Available]
Relationship of Nominee with
12
Account Holder [If Available]
Address of the Nominee
13
(if available)
E Mail ID of Nominee (if
14
available)
Mobile Number of Nominee
15
(if available)
[#Corporate Salary Package (CSP), Defence Salary Package (DSP), Para Military Salary Package
(PMSP), Indian Coast Guard Salary Package (ICGSP), State Government Salary Package (SGSP), Central
Government Salary Package (CGSP), Police Salary Package (PSP) and Railway Salary Package (RSP),
Start-up Salary Package (SUSP)]
(@ STRIKE OUT WHAT IS NOT APPLICABLE)

The foregoing details are true to the best of my / our knowledge and belief.

_________________________________________________ ______________________________________________

Signature of Person Intimating Claim Full Name of person


Intimating Claim

Relationship with Insured __________________________________________________________________________________

_________________________________________________ _____________________________________________

E Mail of Individual Signing Above (if available) Mobile/ Contact Number


of Individual Signing Above

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