Annexure- 5 Oriental Insurance Co. Ltd. SBI GPA Claims Cell or, Oriental House, 7 J. Tata Road, Churchgate, Mumbai- 400020 Group Personal Accident/ Air Accident Claim Form To Be Filled by Nominee/ Claimant/ Legal Heir) Submission of this format for. claim is not to be taken as an admission of liability. 580000/48/2025/152 Address: | SBI GPA Claims Cell, Mumbai Regional Office No. 1, {3rd Floor, Oriental House,7 J. Tata Road, Churchgate, Mumbai-400020. Phone :022-22621746 / 22821459 / 228281365 Toll Free No.: 1800-11-8485 Fax No. 022-22821648 Email Id: sbigpa.claims@orientalinsurance.co.in Cc. pote.ninad@orientalinsurance.co.in paihelpdesk@rathi.com 4 Mumbai Regional Office 1, 2nd Flo 4.04,2024 to 03.04.2025 Name of Salary/Pension Account holder Address of Claimant [Date of Accident [Date of Death of Salary/Pension Account Holde Cause of Death |Salary/Pension Package Account No. - ‘press Credit (PL) Outstanding (if any), for IDSP/CAPSP/ICGSP/PSP only Name of the organization Name of Nominee/loint Account holder in the| salary/pension package account Mobile Number of Nominee/ Joint account older [Contact Number of other close person/relative \Ac No: \0/s as on date: [Branch Wamex \Branch Details where Salary/Pension Account is|Branch Code: Inaintained (Claim Amount (eligibility as per he \variant/Package) ladd on Covers: Rs.Please ensure to enclose below mentioned documents: Please ensure to enclose below mentioned documents: DOCUMENTS TO BE SUBMITTED ALONG WITH ANNEXURE 5 (Claim Form| si ) ne Documents eae Documents Enclosed Viscera Report / Chemical Analysis 1 Annexure 4: Claim Intimation Report in case where postmortem Form VIIl_ | report shows the cause of death due to poisoning or alcohol or confirm after Viscera/Chemical Analysis Report _ Aadhar Card of Nominee/loint Account Annexure 6: x holder /Claimant in the salary package ui Duly stamped and signed | account. Certificate by SBI Branch X-| Salary Ac Statement for last three Bl Manager on Bank Letter head. months and Copy of Salary Slip last three Months (Prior to date of accident) Annexure 7: Bank details/ NEFT Form of PAN card copy of the Nominee/soint " Nominee/Joint Account Account holder/ Claimant in the salary (Claimant holder in the salary package account. if not available, then package account yom eo XIL_ | Attested copy of the first page of the wv Bank Passbook or cancelled Cheque Attested Copy of Death containing the Name of Account Holder Certificate (claimant), IFSC Code of the Bank, Bank Account Number of Nominee/Joint Account holder/ Claimant. XIIl_| Other suitable document to prove legal Vv Attested Copy of Postmortem heirship in case claimant is not a Report nominee / joint account holder as per Bank’s record ree XIV_| In case of multiple heirs, (consent from v__| Attested Copy of FIR Report all the legat hes) |_| Defence Authority report in Certified Copy of Final Police vil case FIR is not available (For XV__| Investigation Report in case of train Armed forces) accident/drowning/murder Lhereby declare that the foregoing statements made by me are true in all respects, that | have not attempted to conceal from the Company anything with which it ought to be made acquainted and that if | have made or in any further declaration the Company may require shall make any false or fraudulent statement or untrue averment whatever, the Claim shall be void and my right to compensation forfeited. | am willing if required, to make and provide to the Company a statutory Declaration of the whole of the foregoing statement or of any other statement made in connection with this claim. Signature of Nominee/Joint Account Holder/Claimant Name Date