Apne liye. Apno ke liye.

INDIVIDUAL DEATH CLAIM FORM

For Official Use Only

Branch Name: Branch Code:

Photograph of
Interaction ID: Claimant
Employee Name:
Employee Code: Sign:

Date: D D M M Y Y Y Y Time: On or Before 3PM After 3PM

SECTION A*
POLICY DETAILS
Policy Number(s): 1) 2) 3)

SECTION B*
DETAILS OF LIFE ASSURED (LA)
Name of Life Assured: Mr. Mrs. First name Middle Name Last Name

First name Middle Name Last Name

Father's /Spouse Name:

Date of Death D D M M Y Y Y Y

Place of Death Hospital Clinic Residence Office Others (Please specify)

Family Doctor: Name Registration No Contact No

Last treated/attended Doctor: Name Registration No Contact No

Last Employer details (If applicable):

Name of the Company Name of contact person

Contact No : Address:
Nature of Death Medical Natural Accident Murder Suicide
Cause of Death

Nature of Illness and Habit of the insured Date of diagnosis of illness

Hypertension Diabetes Heart disease Liver disease Date of admission

Kidney disease Cancer Other Date of discharge

Smoking Tobacco Drugs If yes, Duration of Consumption & Quantity Consumed

Other Insurance details: (Life/Mediclaim/Health)

Policy No. Company Name Sum Assured Status (Active/Lapsed/Applied/Matured)

DETAILS OF CLAIMANT
Claimant Name: Mr. Mrs. F I R S T M I D D L E L A S T

Date of Birth: D D M M Y Y Y Y

Address: R O O M / F L A T N O . F L O O R

B U I L D I N G R O A D N A M E / N O

L A N D M A R K

C I T Y / V I L L A G E

D I S T R I C T S T A T E

Pincode:

Contact No.: O F F I C E R E S I D E N C E M O B I L E

Office & / or Personal Email ID:

Relation with the Life Assured: Spouse Children Parents Others S P E C I F Y

Claimant’s Title: Nominee Executor Trustee Appointee Employer Assignee Beneficiary

Claimant's PAN details:

Politically exposed person: Yes No

“Politically Exposed Persons” PEPs are individuals who are or have been entrusted with prominent public functions in a foreign country, e.g., Heads of States/Governments, senior
politicians, senior government / judicial / military officers, senior executives of state-owned corporations, important political party officials, etc.
Resident Status: Resident Indian / Non Resident Indian (NRI) / Foreign National / Person of Indian Origin (PIO)
Please submit FATCA/CRS certification if resident status is NRI/Foreign National/Person of Indian Origin.

CLAIMANT NEFT MANDATE/ BANK ACCOUNT DETAILS

In case of children's plans, if beneficiary is a major, please provide beneficiary's account details IFSC Code (11Characters)

Bank Account No. :

RUPEE
Account Holder Name: `
Bank Name & Branch:
Account Type Savings Current NRO NRE Account Holder’s Name
MICR Code (9 Characters)
IFSC: MICR:
Mandatory for Pension Plans, Please indicate how you would like to receive the benefits

Entire amount as lumpsum Entire amount as Annuity Part as annuity Part as Lumpsump As Installments

Claim Benefit Payout Option *

Entire amount as lumpsum Entire amount as instalment Lump sum + monthly instalments
In case of instalment, Select Frequency Yearly Half Yearly Quarterly Monthly
Select Term (in years) 2 3 4 5

Applicable for SBI LIFE Pension policies

Entire amount as Annuity Policy Part amount as Annuity Policy & Part as lumpsum
Do you wish to opt annuity from SBI Life or from Market?
SBI Life Market (specify name of company) _____________________________________
* Please refer policy Terms & conditions while selecting the claim benefit payout option.

SECTION C*
DECLARATION AND AUTHORISATION
• I hereby authorize SBI Life to consider details furnished in the claim form specified above and in this declaration for the purpose of Central KYC Registry and to provide my
details to CERSAI in the prescribed format. I hereby consent to receiving information from Central KYC Registry through sms/ email on the above registered number/email
address.
• I hereby declare all the details filled/furnished above are true correct to the best of my knowledge & belief.
• I hereby warrant the truth and correctness of the foregoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement,suppress or
conceal any material fact, my right to claim reimbursement of the said expenses shall be absolutely forfeited.
• I understand and agree that the submission of this form does not mean that the request will be processed.
• I understand that any payout under the policy shall be strictly in accordance with the policy terms and conditions.
• Any payment shall be subject to realization of the last renewal premium payment.
• I authorise all the medical establishments (medical labs included), government institutions (police, revenue, etc.) to reveal the treatment information including HIV / AIDS and
others, related to the LA, to SBI LIFE Insurance Company Limited, from both the past and present.
• A photo copy of this declaration shall be considered as valid and effective.
• I authorise SBI LIFE Insurance Company Limited to share and obtain information on behalf of me with any reinsurer, insurance association, medical authorities, other
insurers, statutory authorities, employer, court, governmental body, regulator using an investigation agency or other service hereby provide my consent for the same.
• 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 SBI 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'
• 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 SBI 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 SBI 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 SBI 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 Rs 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.

Date: D D M M Y Y Y Y

Place: Signature of Claimant

DECLARATION TO BE MADE BY A THIRD PERSON
The Claimant has affixed his/her thumb impression/has signed in vernacular/has not filled the application. I hereby declare that the content of this application form has been

explained to the Claimant in_____________________________________language and have truthfully recorded the answers provided to me. I further declare that the Claimant has

signed/affixed his/her thumb impression in my presence.

Name of the Declarant:

Address:

Date: D D M M Y Y Y Y

Place: Signature of Third Person

Important Note: In case of any demand or favour asked by anyone including a company representative towards claim processing or
settlement, the same should not be entertained and must be reported to the company immediately on the company’s email id:
claims@sbilife.co.in

INSTRUCTION FOR FILLING UP THE FORM

A. IMPORTANT INFORMATION (Please read before filling the form)
1. The form should be filled by the claimant only. In case the claimant is a minor, the guardian/appointee may fill the form
2. Claims under multiple policies may be registered by filling a single form & providing all applicable policy numbers
3. In case of more than one claimant, separate forms need to be filled for each claimant
4. Please read the declarations carefully and the claimant should sign the claim form in the same manner as you normally sign your cheque
5. Claim is payable subject to fulfillment of all terms and conditions of the policy
6. No fee or commission should be paid to anyone to process this claim
7. Make sure your address, phone numbers and email ID are current and active as the correspondence will happen through this only
8. Asterisk (*) refers to mandatory information

B. DOCUMENTS TO BE SUBMITTED
MANDATORY DOCUMENTS
(1) Original policy document (Not necessary in case of dematerialised policy document) (2) Death certificate issued by local authority (3) Claimant's PAN CARD
(4) Claimant's passport size photograph (5) Cancelled cheque
ADDITIONAL DOCUMENTS
HOSPITALISATION/ DEATH DUE TO ILLNESS (1) Medical cause of death certificate (2) Medical records for all the treatments taken in the past.
(Admission notes, History / Progress sheet, Discharge / Death summary, Test reports, etc.) (3) Claimant's passport size photograph (5) Cancelled cheque
ACCIDENTAL DEATH (1) First Information Report (FIR), Panchnama / Inquest report, Post-mortem report (PMR), Driving license, Police Final Report,
Viscera report (if applicable) Newspaper cutting (s), if any, Others as applicable

Disclaimers: 1. Copies to be submitted and originals to be presented at the time claim submission, 2. SBI LIFE Insurance Company Limited reserves the right to ask for more
information/ documents, if required

C. LIST OF VALID IDENTITY & ADDRESS PROOFS (Please tick the document submitted)

PHOTO IDENTIFY PROOF (ANY ONE) ADDRESS PROOF (ANY ONE)

Claimant's PAN CARD Valid Passport Voter ID Card Valid Passport

Aadhar Card* Valid Driving License Voter ID Card

Bank Passbook with stamped photograph (not more than 6 months old) Aadhar Card*

ID Card Issued by Central/State Govt. to employees Driving License

Any other Central/State Govt. issued ID

Job card issued by NREGA duly signed by an officer of the State Government

The letter issued by the National Population Register containing details of

name, address or any other document as notified by the Central Government
in consultation with the Regulator'

*I voluntarily provide my consent to use my Aadhar to conduct identity check towards KYC compliance by SBI Life Insurance Company Limited
 D. NOTE: CLAIMANT NEFT MANDATE/ BANK ACCOUNT DETAILS
• A cancelled personalised cheque with the account no. and IFSC should be submitted along with the NEFT mandate. If the cheque is not personalised, a latest bank
statement or copy of passbook (where account number and IFSC is mentioned) needs to be submitted with the mandate.
• This mandate, upon processing, will override any of the previously tagged NEFT mandates for all policies, held by the client with SBI Life Insurance Company Limited.
• In case of NEFT failure or any further requirements pending on the mandate, payout will be kept on hold till fresh NEFT mandate is received. Intimation will be sent to
you for the same.
#
Refund to NRE account (full or proportionate) will be subject to ratio of premium(s) paid through NRE Account. Please submit a Bank Statement or Bank Confirmation
letter as an evidence for premium(s) paid through NRE account.
##
In case of proportionate payout, please provide two NEFT mandates i.e. for NRE account and non-NRE account.

BEWARE OF SPURIOUS PHONE CALLS AND FICTITIOUS/FRAUDULENT OFFERS

IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving such phone calls are requested to lodge a police complaint.
Trade logo displayed above belongs to State Bank of India and is used by SBI Life under license. Registered and Corporate Office: SBI Life Insurance Company Limited, Natraj,
M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai-400 069 • IRDAI Registration No. 111 • Website: www.sbilife.co.in • Email: info@sbilife.co.in •
Toll free no: 1800 267 9090 (Customer Service timing: 24X7) • CIN: L99999MH2000PLC129113 CLM/INDDTH-1/Ver 1.5/01-24

CUSTOMER ACKNOWLEDGEMENT COPY-INDIVIDUAL DEATH CLAIM FORM

Policy No. Claimant Name
Branch Name / Interaction ID Claimant Client ID
Employee Name Date
Employee Sign Employee Code
Branch Stamp

BEWARE OF SPURIOUS PHONE CALLS AND FICTITIOUS/FRAUDULENT OFFERS

IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving such phone calls are requested to lodge a police complaint.
Trade logo displayed above belongs to State Bank of India and is used by SBI Life under license. Registered and Corporate Office: SBI Life Insurance Company Limited, Natraj,
M.V. Road & Western Express Highway Junction, Andheri (East), Mumbai-400 069 • IRDAI Registration No. 111 • Website: www.sbilife.co.in • Email: info@sbilife.co.in
• Toll free no: 1800 267 9090 (Customer Service timing: 24X7) • CIN: L99999MH2000PLC129113