payor rider claim form

PAYOR RIDER CLAIM FORM
ëšÚ¹ ¹àÒül¡à¹ ƒà[¤ ó¡³¢
CLAIMS DOCUMENT CHECKLIST (CDCL)
ƒà[¤¹ >[=¹ ëW¡A¡[ºÐ¡ ([Î[l¡[Î&º)
Life Assured Name:
\ã¤> [¤³àAõ¡ìt¡¹ >à³
Policy No.:
š[º[Î >}.
• Please submit this form along with the requirements mentioned below at the nearest branch
or address listed overleaf for faster processing of claim.
ƒà[¤¹ ‰ç¡t¡ šø[yû¡ÚàA¡¹ìo¹ \>¸ ">åNøÒ A¡ì¹ [>³¥[º[Jt¡ "à¤Å¸A¡t¡àP¡[º ÎÒ &Òü ó¡³¢[i¡ [>A¡i¡t¡³ ÅàJàÚ "=¤à šõˡ๠[šáì> l¡ü[À[Jt¡ [k¡A¡à>àÚ \³à [ƒ>ú
• Please note that all documents needs to be self attested.
">åNøÒ A¡ì¹ ³ì> ¹àJì¤> ë™ ÎA¡º >[= Ѭ-šøt¡¸[Út¡ Ò*Úà šøìÚà\>ú
Payor Rider Claim Requirements
ëšÚ¹ ¹àÒül¡à¹ ƒà[¤¹ "à¤Å¸A¡t¡à γèÒ
Yes/No
Ò¸òà/>à
1. Original Death Certificate or attested copy thereof issued by Municipal Authorities.
1. ëšï¹ A¡tõ¡¢šÛ¡ ‡à¹à šøƒv¡ "àκ ³õt塸 Îà[i¢¡[ó¡ìA¡i¡ "=¤à ëÎ[i¡¹ šøt¡¸[Út¡ A¡[š
2. Claim Form duly filled, signed by claimant and duly attested by an authorized
person as mentioned in claim form
2. ƒà[¤¹ ó¡³¢ ™=à™= ®¡àì¤ šè¹o A¡¹à, ƒà[¤ƒàì¹¹ ‡à¹à ѬàÛ¡[¹t¡ &¤} ƒà[¤¹ ó¡ì³¢ l¡ü[À[Jt¡ ">åì³à[ƒt¡ ¤¸[v¡û¡¹ ‡à¹à ™=à™= ®¡àì¤ šøt¡¸[Út¡
3. Original Policy Document (s).
3. "àκ š[º[Î >[= (γèÒ)
4. Authorization Form duly filled, signed by claimant
4. ">åì³àƒ> ó¡³¢ ™=à™= ®¡àì¤ šè¹o A¡¹à, ƒà[¤ƒàì¹¹ ‡à¹à ѬàÛ¡[¹t¡
5. Copy of Claimant’s current address proof
5. ƒà[¤ƒàì¹¹ ¤t¡¢³à> [k¡A¡à>๠šø³àošìy¹ A¡[š
6. Copy of Claimant’s Photo Id proof which establishes relationship with life assured
6. ƒà[¤ƒàì¹¹ Î[W¡y š[¹W¡Úšìy¹ A¡[š ™à \ã¤> [¤³àAõ¡ìt¡¹ ÎìU δšA¢¡ [>[ƒ¢Ê¡ A¡ì¹
7. Last Medical Attendant Report
7. ëÅÈ [W¡[A¡;Îà š[¹W¡™¢àA¡à¹ã¹ [¹ìšài¢¡
8. Copies of Medical Records, Test Reports, Discharge/ Death summary, indoor
case papers, Outpatient Consultation Notes
8. [W¡[A¡;Îà Î}yû¡à”z ë¹A¡ìl¢¡¹ A¡[š, š¹ãۡ๠[¹ìšài¡¢, [l¡ÎW¡à\¢ / ìl¡= Îà³à[¹, Òü>ìl¡à¹ ëA¡Î ëššà¹, ¤[Ò[¤¢®¡àìK š¹à³Å¢ A¡¹à¹ ë>ài¡ γèÒ
9. Employer’s questionnaire
9. [>ìÚàKA¡t¡¢à¹ šøťऺã
In case of accidental/ unnatural death, in addition to the above , the following documents are required
ƒåQ¢i¡>à\[>t¡ /"Ѭ஡à[¤A¡ ³õt塸¹ ëÛ¡ìy l¡üšì¹àv¡û¡ áàØl¡à* [>³¥[º[Jt¡ "[t¡[¹v¡û¡ >[=šy šøìÚà\>
10.Copy of First Information Report ( FIR)
10. šø=³ ÎèW¡>à [¹ìšàìi¡¢¹ (&ó¡"àÒü"à¹) A¡[š
11.Copy of Post Mortem Report, Viscera Report
11. ³Ú>à t¡ƒì”z¹ [¹ìšàìi¡¢¹ A¡[š, [®¡ìιà [¹ìšàìi¡¢¹ A¡[š
12. Inquest Panchanama
12. ³õt塸¹ A¡à¹o ">åÎÞê¡à> še¡>à³à
13. Policy Final Investigation Report
13. š[º[ι "[”z³ ">åÎÞê¡à> [¹ìšài¡¢
14. Newspaper cutting
14. Î}¤àƒšìy¹ A¡à[i¡} (™[ƒ =àìA¡)
PAYOR RIDER CLAIM FORM (PRCF)
ëšÚ¹ ¹àÒül¡à¹ ƒà[¤ ó¡³¢ ([š"à¹[Î&ó¡)
1. Policy No.:
š[º[Î >}.
2. Name of Deceased Owner: ³õt¡ ³à[ºìA¡¹ >à³
First Name
Middle Name
šø=³ >à³
Surname
³‹¸ >à³
šƒ[¤
Section I Details of the Claimant
[¤®¡àK I- ƒà[¤ƒàì¹¹ [¤¤¹o
3. Name of Claimant: ƒà[¤ƒàì¹¹ >à³
First Name
Middle Name
Surname
³‹¸ >à³
šø=³ >à³
4. Current Residential Address (Current Address should match with
Address proof provided)
šƒ[¤
Mobile no.:
ì³à¤àÒüº >}.
¤t¢¡³à> ¤Î¤àìι [k¡A¡à>à (¤t¢¡³à> ¤Î¤àìι [k¡A¡à>à šøƒv¡ [k¡A¡à>๠šø³àošìy¹ ÎìU ÎU[t¡šèo¢
Ò*Úà šøìÚà\>)
Phone no.with STD Code: &Î[i¡[l¡ ëA¡àl¡ ÎÒ ëó¡à> >}.
Pin Code:
City:
[š> ëA¡àl¡
ÅÒ¹
Email ID:
Òü쳺 "àÒü[l¡:
5. Relationship with Deceased Owner
\ã¤> [¤³àAõ¡ìt¡¹ ÎìU δšA¢
Section I Details of the Life Insured
[¤®¡àK I \ã¤> [¤³àAõ¡t¡ ¤¸[v¡û¡¹ [¤¤¹o
6. Name of Life Insured \ã¤> [¤³àAõ¡ìt¡¹ >à³
First Name
Middle Name
šø=³ >à³
Surname
³‹¸ >à³
šƒ[¤
Mobile no.:
7. Current Residential Address ¤t¢¡³à> ¤Î¤àìι [k¡A¡à>à
ì³à¤àÒüº >}.
Phone no. with STD Code: &Î[i¡[l¡ ëA¡àl¡ ÎÒ ëó¡à> >}.
Pin Code:
City:
[š> ëA¡àl¡
ÅÒ¹
Email Id:
Òü쳺 "àÒü[l¡:
8. LI’s Occupation and Relationship with Deceased Owner
\ã¤> [¤³àAõ¡ìt¡¹ ³õt¡ ³à[ºìA¡¹ ÎìU δšA¢
9. Title under which the claim is submitted (Please Tick) ì™ Ñ¬â«à[‹A¡àì¹¹ "‹ãì> ƒà[¤ \³à ëƒ*Úà ÒìÚìá (">åNøÒ A¡ì¹ [i¡A¡ [W¡Òû¡ [ƒ>)
1. Nominee
>[³[>
6. Beneficiary
Ѭâ«ì®¡àKã
2. Appointee
[>™åv¡û¡ ¤¸[v¡û¡
3. Survivor
\ã[¤t¡ l¡üv¡¹à[‹A¡à¹ã
4. Assignee
Ѭâ«[>ìÚàKã
5. Trustee
>¸àιۡA¡
7. HUF
[Ò@ƒå "[¤®¡v¡û¡
š[¹¤à¹
10. If there is any other claim underlying the policy, please tick the appropriate box and submit respective claim form for the same.
&Òü š[º[ι \>¸ ™[ƒ ">¸ ìA¡à> ƒà[¤ =àìA¡ t¡àÒìº ">åNøÒ A¡ì¹ ™=à™= ¤àìG [i¡A¡ [W¡Òû¡ [ƒ> &¤} ìÎP¡[º¹ \>¸ Ѭ Ѭ ƒà[¤ ó¡³¢ \³à [ƒ>ú
HCB
&ÒüW¡[Î[¤
Critical Illness
P¡¹ç¡t¡¹ "ÎåÑ‚t¡à
Permanent Total Disability
Ñ‚àÚã δšèo¢ "Û¡³t¡à
Claim/PRCF/Ver1.0/1stApr2011
Section II Details of Deceased Owner
[¤®¡àK II ³õt¡ ³à[ºìA¡¹ [¤¤¹o
Date of Birth
\@µ t¡à[¹J
Date of Death
Time of Death
³õt¡å ¸¹ t¡à[¹J
a.m./p.m.
³õt¡å ¸¹ γÚ
&.&³/[š.&³
Place o Death
³õt塸¹ Ñ‚à>
Cause of Death
³õt塸¹ A¡à¹o
If Place of Death is outside India:
³õt塸¹ Ñ‚à> [A¡ ®¡à¹ìt¡¹ ¤àÒüì¹ "¤[Ñ‚t¡ :
Yes Ò¸òà
No >à
Was the deceased buried or cremated abroad? If yes, enclose a copy of the burial/ cremation permit.
³õt¡ ¤¸[v¡û¡ìA¡ [A¡ [¤ìƒìŠγà[‹Ñ‚ A¡¹à ¤à Ť ƒàÒ A¡¹à ÒìÚìá? ™[ƒ Ò¸òà ÒÚ t¡àÒìº Î³à[‹Ñ‚ A¡¹à /Ť ƒàÒ A¡¹à¹ ">å³[t¡ šìy¹ &A¡[i¡ A¡[š Î}™åv¡û¡ A¡¹ç¡>¡ú
Employment Details: Name of the Employer’s /Business Name
A¡ì³¢ [>™å[v¡û¡¹ [¤¤¹o: [>ìÚàKA¡t¡¢à¹ >à³/¤¸¤Î๠>à³
Address :
[k¡A¡à>à
City & Pin Code :
Mobile or Phone no.
ÅÒ¹ &¤} [š> ëA¡àl¡ :
ì³à¤àÒüº "=¤à ìó¡à> >}.
Exact nature of Job/ Business
A¡à\/¤¸¤Î๠™=à=¢ šøAõ¡[t¡
Death due to Accident: Date of Accident
ƒåQi¢ ¡>๠A¡à¹ìo ³õt¡å ¸ : ƒåQi¢ ¡>๠t¡à[¹J
Time of Accident
a.m./p.m.
ƒåQi¢ ¡>๠γÚ
&.&³/[š.&³
Place of Accident
ƒåQ¢i¡>๠тà>
Please provide duly attested copy of documents mentioned in the checklist for accidental death (From 8 to 12) (Mandatory)
">åNøÒ A¡ì¹ ƒåQ¢i¡>à\[>t¡ ³õt塸¹ \>¸ ëW¡A¡[ºìÐ l¡ü[À[Jt¡ ¡>[=šìy¹ ™=à™= ¹ê¡ìš šøt¡¸[Út¡ A¡[š šøƒà> A¡¹ç¡> (ó¡³¢ 8 ë=ìA¡ 12) (¤à‹¸t¡à³èºA¡)
Death due to Illness: Date of First Complaint of Symptoms
"ÎåÑ‚t¡à¹ A¡à¹ìo ³õt塸 : ë™ t¡à[¹ìJ šø=³ l¡üšÎìK¢¹ "[®¡ì™àK \à[>ìÚ[áìº>
Name of the Doctor/Hospital who was consulted for illness’s during the last three years.
ëÅÈ [t¡> ¤áì¹ ë™ [W¡[A¡;ÎA¡/ÒàΚàt¡àº ë=ìA¡ š¹à³Å¢ NøÒo A¡ì¹[áìº> t¡à¹ >ೡú
Name of the Doctor/
Hospital or Clinic
[W¡[A¡;ÎA¡ /ÒàΚàt¡àº ¤à [Aá[>ìA¡¹ >à³
Address, Contact No
[k¡A¡à>à, ë™àKàì™àìK¹ >}
Date of Consultation
š¹à³Å¢ NøÒo A¡¹à¹ t¡à[¹J
Nature of Illness
"ÎåÑ‚t¡à¹ ‹¹>
Claim/PRCF/Ver1.0/1stApr2011
Section III: Details of Other Life Insurance Policies on the life of the deceased
[¤®¡àK III: ³õt¡ ¤¸[v¡û¡¹ \ã¤ì>¹ l¡üš¹ A¡¹à ">¸à>¸ \ã¤> [¤³à¹ [¤¤¹o
Policy No.
š[º[Î >}.
Sum Assured
"àÅ«à[Ît¡ "=¢¹à[Å
Name of Insurance
Company
[¤³à ìA¡à´šà[>¹ >à³
Date of
Commencement
W¡àºå A¡¹à¹ t¡à[¹J
Claim Status
Rider Coverage
(If any)
ƒà[¤¹ [Ñ‚[t¡
¹àÒül¡à¹ "àZáàƒ> (™[ƒ =àìA¡)
Declaration:
ìQàÈoà:
In connection with claim under policy no. š[º[Î >}.
&¹ ƒà[¤ δšìA¢¡
for Rs. ____________________________on the life of __________________________________Owner , I _______________________
Claimant, do hereby declare that the statement made herein above I true in each and every respect.
___________________________ ( ³à[ºA¡) &¹ \ã¤ì>¹ l¡üš¹___________ i¡àA¡à¹¡\>¸, "à[³ ______________________, (ƒà[¤ƒà¹)&t¡‡à¹à ìQàÈoà A¡¹[á ë™ l¡üšì¹ [¤¤õt¡ ÎA¡º t¡=¸
Τ¢à}ìÅ Ît¡¸ú
*Countersigned By:
*šø[t¡-ѬàÛ¡[¹t¡ A¡ì¹ìá>
Date t¡à[¹J
Designation
šƒ
Signature of the Claimant:
ƒà[¤ƒàì¹¹ ѬàÛ¡¹
Address:
[k¡A¡à>à
Address:
[k¡A¡à>à
Certified that the contents of this form were explained to the declarant in vernacular and he/she has affixed is/ her
signature/ thumb impression hereto after fully understanding the same.
šøt¡¸à[Út¡ ë™ &Òü ó¡ì³¢¹ [¤ÈÚ¤Ññ ìQàÈoàA¡à¹ãìA¡ t¡à¹ ³àtõ¡®¡àÈàÚ ¤å[c¡ìÚ ¤ºà ÒìÚìá &¤} [t¡[> ëÎ[i¡ δšèo¢ ®¡àì¤ ì¤àc¡à¹ šì¹ &ìt¡ ѬàÛ¡¹ šøƒà> A¡ì¹ìá>/¤õ‡ý¡àUåìË¡¹ áàš [ƒìÚìá>ú
Signature
ѬàÛ¡¹
Name of the Witness:
ÎàÛ¡ã¹ >à³:
Designation
šƒ
Address:
[k¡A¡à>à
* This statement must be countersigned by: (1) an Advocate (2) A Bank Manager (3) A Medical Practitioner (4) A Gazette Officer (5) A Head
Master/ Principal of a local Govt. High School (6) A magistrate (7) President Of A Village Panchayat or Local Board (8) Sales Manager
* &Òü [¤¤õ[t¡ [>ì³¥àv¡û¡ ìA¡à> &A¡\> ¤¸[v¡û¡ ‡à¹à šø[t¡ ѬàÛ¡[¹t¡ Ò*Úà šøìÚà\> (1) &A¡\> "àÒü>\ã¤ã (2) &A¡\> ¤¸à}A¡ ³¸àì>\๠(3) &A¡\> [W¡[A¡;ÎA¡ (4) &A¡\> ëKì\ìi¡l¡
"[ó¡Î๠(5) Ñ‚à>ãÚ Î¹A¡à¹ã l¡üZW¡ [¤ƒ¸àºìÚ¹ šø‹à> [ÅÛ¡A¡ / [šø[Xš¸àº (6) &A¡\> ³¸à[\ìСöi¡ (7) Nøà³ še¡àìÚt¡ "=¤à Ñ‚à>ãÚ ì¤àìl¢¡¹ ή¡àš[t¡ (8) ëκΠ³¸àì>\à¹
Claim/PRCF/Ver1.0/1stApr2011
AUTHORISATION
">åì³àƒ>
(To be filled & signed by the Claimant)
(ƒà[¤ƒà¹ ‡à¹à šè¹o A¡¹à &¤} ѬàÛ¡[¹t¡ Ò*Úà šøìÚà\>)
Life Insurance Policy No.(s)
\ã¤> [¤³à š[º[Î >}(γèÒ)
I, Mr. / Mrs / Ms. ______________________________________ (name of the claimant), _______________________________
________________ (relation with Life Assured) hereby give my consent to M/s Aviva Life Insurance Company India Limited, and
/ or its representative to obtain all employment / medical / hospital records / police records / other records (including photocopies)
/ information pertaining to the treatment / occupation of the deceased Life Assured which he/ they may have acquired whether
before or after the policy as well as details from other Life Insurance Companies regarding any existing policies which he / they
may have sourced before or after the initiation of this contract.
"à[³, Åøã/Åøã³t¡ã/A塳à¹ã __________________________________ (ƒà[¤ƒàì¹¹ >à³), __________________________________________
(\ã¤> [¤³àAõ¡ìt¡¹ ÎìU δšìA¢¡) &t¡‡à¹à "[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹X ìA¡à´šà[> Òü[“¡Úà [º[³ìi¡l¡ &¤}/"=¤à &¹ šø[t¡[>[‹ìA¡ ™à¤t¡ãÚ A¡³¢ [>ìÚàK/ [W¡[A¡;Îà/ ÒàΚàt¡à캹
ë¹A¡l¢¡/šå[ºÅ ë¹A¡l¢¡ /">¸à>¸ ë¹A¡l¢¡ (ó¡ìi¡àA¡[š ÎÒ) /[W¡[A¡;Îà Î}yû¡à”z t¡=¸ /ìA¡à´šà[> š[º[Î šøƒà> A¡¹à¹ "àìK ¤à šì¹ ³õt¡ \ã¤> [¤³àAõ¡ìt¡¹ ‡à¹à KõÒãt¡ \ã[¤A¡à &¤}
t¡;ÎÒ &Òü Wå¡[v¡û¡ δšàƒì>¹ šè줢 ¤à šì¹ tò¡à¹/t¡à샹 A¡¹à [¤ƒ¸³à> ìA¡à>* š[º[ΠδšìA¢¡ ">¸à>¸ \ã¤> [¤³à ìA¡à´šà[>¹ ë=ìA¡ [¤¤¹o šøàœ¡ A¡¹à¹ ">å³[t¡ šøƒà> A¡¹[áú
Yours faithfully
Date t¡à[¹J
"àš>๠">åKt¡
Place:
Ñ‚à>
(Signature of Claimant)
(ƒà[¤ƒàì¹¹ ѬàÛ¡¹)
Contact details of the claimant:
ƒà[¤ƒàì¹¹ ÎìU ì™àKàì™àìK¹ t¡=¸
Address:
[k¡A¡à>à
Pin
[š>
Landline: STD Code
º¸à“¡ºàÒü>: &Î[i¡[l¡ ìA¡àl
No.
>}.
Mobile:
ì³à¤àÒüº >}.
Email id:
Òü쳺 "àÒü[l¡:
Claim/PRCF/Ver1.0/1stApr2011
ACKNOWLEDGEMENT SLIP
šøà[œ¡Ñ¬ãA¡à¹ šy
Policy No.:
š[º[Î >}.
Name of Claimant:
ƒà[¤ƒàì¹¹ >à³
Interaction ID:
Òü@i¡à¹¸àA¡Å> "àÒü[l¡
Documents Submitted: Please Tick \³à ëƒ*Úà >[=šy: ">åNøÒ A¡ì¹ [i¡A¡ [W¡Òû¡ [ƒ>
Attested Death Claim Form and Signed by the Claimant
šøt¡¸[Út¡ ³õt塸 ƒà[¤ ó¡³¢ &¤} ƒà[¤ƒà¹ ‡à¹à ѬàÛ¡[¹t¡
Original Death Certificate or attested copy thereof issued by Municipal Authorities
ëšï¹ A¡tõ¡¢šÛ¡ ‡à¹à šøƒv¡ "àκ ³õt塸 Îà[i¢¡[ó¡ìA¡i¡ "=¤à ëÎ[i¡¹ šøt¡¸[Út¡ A¡[š
Original Policy Document (s)
"àκ š[º[Î >[= (γèÒ)
Copy of Claimant’s current address proof
ƒà[¤ƒàì¹¹ ¤t¡¢³à> [k¡A¡à>๠šø³àošìy¹ A¡[š
Copy of Claimant’s Photo Id proof which establishes relationship with life assured
ƒà[¤ƒàì¹¹ Î[W¡y š[¹W¡Úšìy¹ A¡[š ™à \ã¤> [¤³àAõ¡ìt¡¹ ÎìU δšA¢¡ [>[ƒ¢Ê¡ A¡ì¹
Last Medical Attendant Report
ëÅÈ [W¡[A¡;Îà š[¹W¡™¢àA¡à¹ã¹ [¹ìšài¢¡
Medical Records
[W¡[A¡;Îà ë¹A¡l¢¡
Employer’s Questionnaire
[>ìÚàKA¡t¡¢à¹ šøťऺã
Copy of First Information Report (FIR)
šø=³ ÎèW¡>à [¹ìšàìi¡¢¹ (&ó¡"àÒü"à¹) A¡[š
Copy of Post Mortem Report, Viscera Report
³Ú>à t¡ƒì”z¹ [¹ìšàìi¡¢¹ A¡[š, [®¡ìιà [¹ìšàìi¡¢¹ A¡[š
Inquest Panchanama
³õt塸¹ A¡à¹o ">åÎÞê¡à> še¡>à³à
Policy Final Investigation Report
š[º[ι "[”z³ ">åÎÞê¡à> [¹ìšài¡¢
Newspaper Cutting
Î}¤àƒšìy¹ A¡à[i¡}
BRANCH STAMP WITH RECEIPT DATE
šøà[œ¡¹ t¡à[¹J ÎÒ ÅàJ๠С¸à´š
Processed by (Name & Signature):
šøìÎÎ A¡ì¹ìá> (>à³ &¤} ѬàÛ¡¹)
Claim Contact Points ƒà[¤¹ \>¸ ë™àKàì™àK Ñ‚º
Mailing Address:
For any urgent queries contact:
Aviva Life Insurance Company
India Ltd. 3rd Floor. Aviva
Towers, Sector-43,
Opposite DLF Golf Course,
Gurgaon-122003
Customer service Helpline Number
1800-180-22-66 (Toll Free)
0124-2709046
šy šàk¡àì>๠[k¡A¡à>à
:
"[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹X ìA¡à´šà[> Òü[“¡Úà [º[³Ìi¡l
3Ú t¡º "[®¡®¡à i¡à*Úà¹, ëÎC¡¹- 43, [l¡&º&ó¡ Kºó¡ ëA¡àë΢¹
[¤š¹ãìt¡, P¡¹Kòà*-122003
ìA¡à> \¹ç¡[¹ šøÅ¥ =àA¡ìº ë™àKàì™àK A¡¹ç¡> :
NøàÒA¡ š[¹ìȤà ÎÒàÚt¡à >´¬¹
1800‐180‐22‐66 (ëi¡àº [óø¡)
0124‐2709046
For any queries please
write to:
[email protected]
ìA¡à> [\`¡àθ =àA¡ìº šy šàk¡à> &Òü [k¡A¡à>àÚ:
[email protected]
Claim/PRCF/Ver1.0/1stApr2011