ªÀÄgÀt ¥ÀæªÀiÁt ¥ÀvÀæ (r¹J¥sï) ºÀPÀÄÌ

DEATH CLAIM FORM (DCF)
ªÀÄgÀt ¥ÀæªÀiÁt ¥ÀvÀæ (r¹J¥sï)
CLAIMS DOCUMENT CHECKLIST (CDCL)
ºÀPÀĄ̈ÁzsÀåvÉUÀ¼À zÁR¯É ¥ÀnÖ (¹r¹J¯ï)
Life Assured Name:
«ªÀiÁzÁgÀ£À ºÉ¸ÀgÀÄ:
Policy No.:
¥Á°¹ ¸ÀASÉå:
Please submit this form along with the requirements mentioned below at the nearest branch or address mentioned
overleaf for faster processing of claim
Documents fro m 6 to12 not required in Pension Policies (other than Pension Elite)
Please note that all documents needs to be self attested.
Claim Document
Please tick the
documents submitted
1. Original Death Certificate or attested copy thereof issued by Municipal Authorities.
2. Original Policy Document (s).
3. Claim Form duly filled, signed by claimant and duly attested by an authorized
person as mentioned in claim form
4. Copy of Claimant’s current address proof
5. Authorization Form duly filled, signed by claimant
6. Copy of Claimant’s Photo Id proof which establishes relationship with life assured
7. Copy of signed cancelled cheque (Mandatory) with NEFT Mandate Form
8.Last Medical Attendant’s Report
9. Copies of all past Medical Records, Diagnostic Test Reports, Discharge/ Death
summary
10.Employer’s questionnaire
In case of accidental/ unnatural death, in addition to the above , the following documents are required
11.Copy of First Information Report ( FIR)
12.Copy of Post Mortem Report, Viscera Report
13.Inquest Panchanama
14.Policy Final Investigation Report
15.Newspaper cutting (If any)
Claim/DCF/Ver1.0/1stApr2011
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«¼Á¸ÀPÉÌ F CfðAiÉÆA¢UÉ ¸À°è¹.
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J¯Áè zÁR¯ÉUÀ¼ÀÆ ¸ÀéAiÀÄA-zÀÈrüÃPÀÈvÀªÁVgÀ¨ÉÃPÉA§ÄzÀ£ÀÄß zÀAiÀÄ«lÄÖ UÀªÀĤ¹.
ºÀPÀĄ̈ÁzsÀåvÉ zÁR¯É
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2. ªÀÄÆ® ¥Á°¹ zÁR¯É(UÀ¼ÀÄ).
3. ºÀPÀĄ̈ÁzsÀåvÉ CfðAiÀÄ°è ºÉýzÀAvÉ CfðAiÀÄÄ ºÀPÀÄÌzÁgÀjAzÀ vÀÄA©¹, ¸À» ªÀiÁr
¸ÀéAiÀÄA-zÀÈrüÃPÀÈvÀªÁVgÀ¨ÉÃPÀÄ.
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5. ºÀPÀÄÌzÁgÀjAzÀ vÀÄA©, ¸À» ªÀiÁqÀ®àlÖ C¢üPÀÈvÀ C¢üPÁgÀzÀ Cfð
6. «ªÉÄUÉƼÀUÉÆAqÀ ¸ÀzÀ¸Àå£ÉÆA¢V£À ¸ÀA§AzsÀªÀ£ÀÄß zÀÈqsÀUÉƽ¸À®Ä ºÀPÀÄÌzÁgÀ£À ¨sÁªÀavÀæ
UÀÄgÀÄvÀÄ ¥ÀÄgÁªÉAiÀÄ ¥Àæw
7. J£ïEJ¥sïn DzÉñÀzÀ CfðAiÉÆA¢UÉ ¸À» ªÀiÁr gÀzÀÄÝUÉƽ¹zÀ ZÉPï£À ¥Àæw (PÀqÁØAiÀÄ)
8. PÉÆ£ÉAiÀÄ ªÉÊzÀåQÃAiÀÄ ¸ÉêÁzÁgÀ¤AzÀ ¤ÃqÀ®àlÖ ªÉÊzÀåQÃAiÀÄ ªÀgÀ¢AiÀÄ ¥Àæw
9. »A¢£À J¯Áè ªÉÊzÀåQÃAiÀÄ zÁR¯ÉUÀ¼ÀÄ, gÉÆÃUÀ¥ÀvÉÛ ¥ÀjÃPÉëAiÀÄ ªÀgÀ¢UÀ¼ÀÄ, ©qÀÄUÀqÉ/ªÀÄgÀtzÀ
¸ÀAQë¥ÀÛ «ªÀgÀ
10. ªÀiÁ°PÀ£À ¥Àæ±ÉÆßÃvÀÛgÀ ¥ÀnÖ
C£ÉʸÀVðPÀ/DPÀ¹äPÀ ¸Á«£À ¸ÀAzÀ¨sÀðzÀ°è, ªÉÄÃ¯É ºÉýgÀĪÀÅzÀ®èzÉÃ, PɼÀV£À zÁR¯ÉUÀ¼ÀÆ ¨ÉÃPÁUÀÄvÀÛªÉ
11. ªÉÆzÀ® ªÀiÁ»w ªÀgÀ¢ (J¥sïLDgï)AiÀÄ ¥Àæw
12. ªÀÄgÀuÉÆÃvÀÛgÀ ±ÀªÀ¥ÀjÃPÉëAiÀÄ ªÀgÀ¢, DAvÀæ ªÀgÀ¢
13. «ZÁgÀuÁ ¥ÀAZÀ£ÁªÉÄ
14. ¥Á°¹AiÀÄ PÉÆ£Éà «ZÁgÀuÁ ªÀgÀ¢
15. ªÁvÁð¥ÀwæPÁ ªÀgÀ¢AiÀÄ vÀÄAqÀÄ (EzÀÝgÉ)
¸À°è¸À®àlÖ zÁR¯ÉUÀ¼À£ÀÄß
UÀÄgÀÄw¹
DEATH CLAIM FORM (DCF)
ªÀÄgÀt ¥ÀæªÀiÁt ¥ÀvÀæ (r¹J¥sï)
1.Policy No.:
¥Á°¹ ¸ÀASÉå.:
2.Name of Deceased Life Assured: ªÀÄÈvÀ «ªÀiÁzÁgÀ ¸ÀzÀ¸Àå£À ºÉ¸ÀgÀÄ:
First Name ªÉÆzÀ® ºÉ¸ÀgÀÄ
Surname PÀÄ®£ÁªÀÄ
Middle Name ªÀÄzsÀåzÀ ºÉ¸ÀgÀÄ
Section I -Details of the Claimant
ºÀPÀÄÌzÁgÀ£À ¸ÉPÀë£ï IgÀ «ªÀgÀUÀ¼ÀÄ
3.Name of Claimant ºÀPÀÄÌzÁgÀ£À ºÉ¸ÀgÀÄ
First Name ªÉÆzÀ® ºÉ¸ÀgÀÄ
Surname PÀÄ®£ÁªÀÄ
Middle Name ªÀÄzsÀåzÀ ºÉ¸ÀgÀÄ
4. Current Residential Address ¥Àæ¸ÀÄÛvÀ ªÀ¸Àw «¼Á¸À:
(Current Address should match with Address proof provided)
(¥Àæ¸ÀÄÛvÀ «¼Á¸ÀªÀÅ F ªÉÆzÀ¯Éà ¸À°è¹gÀĪÀ «¼Á¸À ¥ÀÄgÁªÉUÉ ºÉÆAzÀĪÀAwgÀ¨ÉÃPÀÄ.)
Mobile no.:
ªÉƨÉÊ¯ï ¸ÀASÉå.:
Phone no. with STD Code:
J¸ïnr PÉÆÃqï£ÉÆA¢UÉ zÀÆgÀªÁt ¸ÀASÉå:
City:
Pin Code:
Email ID:
¦£ï PÉÆÃqï:
£ÀUÀgÀ:
E-ªÉÄÃ¯ï «¼Á¸À:
5. Relationship with Life Insured
«ªÀiÁzÁgÀ£ÉÆA¢V£À ¸ÀA§AzsÀ
6. Title under which the claim is submitted (Please Tick) ºÀPÀĄ̈ÁzsÀåvÉAiÀÄ ¨ÉÃrPÉAiÀÄÄ AiÀiÁjAzÀ ¸À°è¸À®ànÖzÉ (zÀAiÀÄ«lÄÖ UÀÄgÀÄw¹)
1. Nominee
£ÉêÀÄPÁwAiÀÄļÀîªÀgÀÄ
6. Beneficiary
ZÁ£À¥ÀqÉAiÀÄĪÀªÀ
2. Appointee
£ÉëĸÀ®àlÖªÀgÀÄ
3. Survivor
GvÀÛgÀfëvÁ¢üPÁj
4. Assignee
¤AiÉÆÃf¸À®àlÖªÀgÀÄ
5. Trustee
læ¹Öà (¤PÉëÃ¥ÀzsÁj)
7. HUF JZïAiÀÄÄJ¥sï
7. Bank Account Details: Please find enclosed NEFT Mandate Form
¨ÁåAPï SÁvÉAiÀÄ «ªÀgÀUÀ¼ÀÄ: zÀAiÀÄ«lÄÖ ®UÀwÛ¸À¯ÁzÀ J£ïEJ¥sïn PÀqÁØAiÀÄ CfðAiÀÄ£ÀÄß UÀªÀĤ¹
Mandatory: (Please attach a copy of signed cancelled cheque along with this form)
PÀqÁØAiÀÄ: (zÀAiÀÄ«lÄÖ ¸À»ªÀiÁr gÀzÀÄÝUÉƽ¹zÀ ZÉPï£À ¥ÀæwAiÀÄ£ÀÄß F CfðAiÉÆA¢UÉ ®UÀwÛ¹)
8. If there is any other claim underlying the policy, please tick the appropriate box and submit respective c laim
form for the same.
¥Á°¹AiÀÄ°è E£ÉßãÁzÀgÀÆ ºÀPÀĄ̈ÁzsÀå ¨ÉÃrPɬÄzÀÝgÉ zÀAiÀÄ«lÄÖ ¸ÀjAiÀiÁzÀ ZËPÀzÀ°è UÀÄgÀÄw¹ ªÀÄvÀÄÛ CzÀPÁÌV ¸ÀA§AzsÀ¥ÀlÖ ºÀPÀĄ̈ÉÃrPÉAiÀÄ CfðAiÀÄ£ÀÄß ¸À°è¹.
HCB
Jz﹩
Critical Illness
wêÀæ C¸ËRå
Section II Details of Deceased Life Insured
Date of Birth:
d£Àä ¢£ÁAPÀ:
Permanent Total Disability
±Á±ÀévÀ ¸ÀA¥ÀÆtð C¸ÁªÀÄxÀåð
ªÀÄÈvÀ «ªÀiÁzÁgÀ£À ¸ÉPÀë£ï II «ªÀgÀUÀ¼ÀÄ
Claim/DCF/Ver1.0/1stApr2011
Date of Death
ªÀÄgÀtzÀ ¢£ÁAPÀ:
Time of Death
ªÀÄgÀtzÀ ¸ÀªÀÄAiÀÄ:
a.m./p.m.
¨É¼ÀUÉÎ/ªÀÄzsÁåºÀß
J.JªÀiï/¦.JªÀiï
Place of Death ªÀÄgÀtzÀ ¸ÀܼÀ:
Cause of Death ªÀÄgÀtPÉÌ PÁgÀt:
If Place of Death is outside India:
Yes ºËzÀÄò
MAzÀÄ ªÉÃ¼É ªÀÄgÀtªÀÅ ¨sÁgÀvÀ¢AzÀ ºÉÆgÀzÉñÀzÀ¯ÁèVzÀÝgÉ:
No C®è
Was the deceased buried or cremated abroad? If yes, enclose a copy of the burial/ cremation permit.
ªÀÄÈvÀ£À£ÀÄß «zÉñÀzÀ°è ¸ÀÄqÀ¨ÉÃPÁ¬ÄvÉà CxÀªÁ ºÀƼÀ¨ÉÃPÁ¬ÄvÉ? ºËzÉAzÁzÀ°è, ¸ÀÄqÀĪÀÅzÀPÁÌV / ºÀƼÀĪÀÅzÀPÁÌV ¤ÃrzÀ C£ÀĪÀÄwAiÀÄ ¥ÀæwAiÀÄ£ÀÄß ®UÀwÛ¹.
Employment Details: Name of the Employer’s /Business Name GzÉÆåÃUÀ «ªÀgÀUÀ¼ÀÄ: MqÉAiÀÄ£À ºÉ¸ÀgÀÄ/¸ÀA¸ÉÜAiÀÄ ºÉ¸ÀgÀÄ:
Address :
«¼Á¸À:
City & Pin Code :
£ÀUÀgÀ & ¦£ï PÉÆÃqï¡:
Mobile or Phone no.:
ªÉƨÉʯï CxÀªÁ zÀÆgÀªÁt ¸ÀASÉå:
Exact nature of Job/ Business:
PÉ®¸ÀzÀ/ªÀåªÀºÁgÀzÀ ¤RgÀ jÃw¡:
Death due to Accident: Date of Accident:
ªÀÄgÀt C¥ÀWÁvÀ¢AzÁVzÀÝgÉ: C¥ÀWÁvÀªÁzÀ ¢£ÁAPÀ:
Time of Accident:
C¥ÀWÁvÀzÀ ¸ÀªÀÄAiÀÄ:
a.m./ p.m.
¨É¼ÀUÉÎ/ªÀÄzsÁåºÀß
J.JªÀiï/¦.JªÀiï
Place of Accident:
C¥ÀWÁvÀzÀ ¸ÀܼÀ:
Please provide duly attested copy of documents mentioned in the checklist for accidental death (From 8 to 12)(Mandatory)
zÀAiÀÄ«lÄÖ DPÀ¹äPÀ ªÀÄgÀtzÀ CfðUÁV EgÀĪÀ ¥ÀnÖAiÀÄ°è MzÀV¹ (8 jAzÀ 12) (PÀqÁØAiÀÄ)
Death due to Illness: Date of First Complaint of Symptoms:
ªÀÄgÀtªÀÅ C¸ËRå¢AzÁVzÀÝgÉ: PÁ¬Ä¯ÉAiÀÄ ®PÀëtUÀ¼À ¥ÀæxÀªÀÄ UÀÄgÀÄw£À ¢£ÁAPÀ:
Name of the Doctor/
Hospital or Clinic
who declared death
Name of the Doctor/
Hospital or Clinic
consulted during
last illness
Address, Contact No
ªÀÄgÀtªÀ£ÀÄß WÉÆö¹zÀ
ªÉÊzÀågÀ/D¸ÀàvÉæAiÀÄ CxÀªÁ
aQvÁì®AiÀÄzÀ ºÉ¸ÀgÀÄ
PÉÆ£ÉAiÀÄ ¨Áj C¸ËRå«zÁÝUÀ «¼Á¸À, ¸ÀA¥ÀPÀð ¸ÀASÉå
¨sÉÃn ªÀiÁr ¸ÀªÀiÁ¯ÉÆÃa¹zÀ
ªÉÊzÀågÀ/D¸ÀàvÉæAiÀÄ CxÀªÁ
aQvÁì®AiÀÄzÀ ºÉ¸ÀgÀÄ
Date of Consultation
Nature of Illness
¸ÀªÀiÁ¯ÉÆÃZÀ£ÉAiÀÄ ¢£ÁAPÀ
C¸ËRåzÀ UÀÄt®PÀët
Claim/DCF/Ver1.0/1stApr2011
Name of the Doctor/Hospital who was consulted for present illness or any oth er illness during the last three years.
Name of the Doctor/
Address, Contact No
Date of
Nature of Illness
Hospital or Clinic
Consultation
EwÛÃZÉV£À C¸ËRåzÀ PÁgÀtPÁÌV CxÀªÁ PÀ¼ÉzÀ ªÀÄÆgÀÄ ªÀµÀðUÀ¼À°è AiÀiÁªÀÅzÉà EvÀgÀ PÁ¬Ä¯ÉUÀ½UÁV ¨sÉÃn ªÀiÁrzÀ ªÉÊzÀågÀ/D¸ÀàvÉæAiÀÄ ºÉ¸ÀgÀÄ
ªÉÊzÀågÀ/D¸ÀàvÉæAiÀÄ CxÀªÁ
aQvÁì®AiÀÄzÀ ºÉ¸ÀgÀÄ
«¼Á¸À, ¸ÀA¥ÀPÀð ¸ÀASÉå
C¸ËRåzÀ UÀÄt®PÀët
Sum Assured
Name of
Insurance
Company
Date of
Commencement
Claim Status
Rider Coverage
(if any)
MlÄÖ ªÉÆvÀÛ
fêÀ«ªÀiÁ PÀA¥É¤AiÀÄ
ºÉ¸ÀgÀÄ
¥ÁægÀA©ü¹zÀ ¢£ÁAPÀ
ºÀPÀĄ̈ÁzsÀåvÉAiÀÄ ¹Üw
gÉÊqÀgï PÀªÀgÉÃeï (EzÀÝgÉ)
Policy no.
¥Á°¹ ¸ÀASÉå.
¸ÀªÀiÁ¯ÉÆÃZÀ£ÀAiÀÄ
¢£ÁAPÀ
Claim/DCF/Ver1.0/1stApr2011
Declaration: WÉÆõÀuÉ:
In connection with claim under policy no.
for Rs.
on the life of
Life Insured , I
hereby declare that the statement made herein above I true in each and every respect.
Claimant, do
¥Á°¹ ¸ÀASÉå ________________________ AiÀÄrAiÀÄ°è ºÀPÀĄ̈ÁzsÀåvÁ ¨ÉÃrPÉUÉ ¸ÀA§A¢ü¹ _________________________
fêÀzÀ ªÉÄÃ¯É gÀÆ ________________________ gÀµÀÄÖ «ªÉÄAiÀÄ£ÀÄß ªÀiÁqÀ¯ÁVzÉ, £Á£ÀÄ _________________________ ºÀPÀÄÌzÁgÀ, ªÉÄÃ¯É ¤ÃrzÀ ºÉýPÉAiÀÄ°è
¥ÀæwAiÉÆAzÀÄ ¸ÀvÀå ªÀÄvÀÄÛ £À£Àß Cj«£ÉÆA¢UÉ ¤ÃrgÀĪÀÅzÉAzÀÄ £Á£ÀÄ F ªÀÄÆ®PÀ WÉÆö¸ÀÄvÉÛãÉ.
*Countersigned By:
*¸ÀvÁå¥À£ÉAiÉÆA¢V£À ¸À»:
Signature of the Claimant:
ºÀPÀÄÌzÁgÀ£À ¸À»:
Date ¢£ÁAPÀ:
Date ¢£ÁAPÀ:
DesiGnation ¥ÀzÀ£ÁªÀÄ:
Address:
«¼Á¸Àt:
Address:
«¼Á¸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.
F CfðAiÀÄ «ªÀgÀUÀ¼À£ÀÄß WÉÆõÀuÁPÁgÀ¤UÉ ¥ÁæzÉòPÀ ¨sÁµÉAiÀÄ°è «ªÀj¸À¯ÁVzÉ ªÀÄvÀÄÛ EzÀ£ÀÄß ¸ÀA¥ÀÆtðªÁV CjvÀÄPÉÆAqÀÄ DvÀ/DPÉ vÀ£Àß ¸À»/ºÉ¨ÉâlÖ£ÀÄß
ªÀiÁrzÁÝgÉAzÀÄ F ªÀÄÆ®PÀ ¸ÀªÀÄyð¸À¯ÁVzÉ.
Signature:
¸À»:
Name of the Witness: ¸ÁQëAiÀÄ ºÉ¸ÀgÀÄ:
Designation:
Address:
¥ÀzÀ£ÁªÀÄ:
¢£ÁAPÀt:
* This statement must be countersigned by any of the following : (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 of Aviva Life Insurance
Company India Limited
*F ºÉýPÉAiÀÄÄ ¸ÀvÁå¥À£ÉAiÉÆA¢UÉ F PɼÀV£ÀªÀjAzÀ ¸À» ªÀiÁqÀ®àqÀ¨ÉÃPÀÄ: (1) ªÀQî (2) ¨ÁåAPï ªÀiÁå£ÉÃdgï (3) ªÉÊzÀå ªÀÈwÛAiÀĪÀgÀÄ (4) UÉeÉómÉqï C¢üPÁj
(5) ªÀÄÄSÉÆåÃ¥ÁzsÁåAiÀÄgÀÄ/¸ÀܽÃAiÀÄ ¸ÀgÀPÁjà ¥ËqsÀ±Á¯ÉAiÀÄ ¥ÁæA±ÀÄ¥Á®gÀÄ (6) £ÁåAiÀiÁ¢ü¥Àw (7) ¸ÀܽÃAiÀÄ ªÀÄAqÀ½ CxÀªÁ UÁæªÀÄ ¥ÀAZÁAiÀÄwAiÀÄ CzsÀåPÀë
(8) C«ªÁ fêÀ«ªÀiÁ PÀA¥À¤ EArAiÀiÁ °«ÄmÉqï£À «PÀæAiÀÄ ¤ªÁðºÀPÀ
Claim/DCF/Ver1.0/1stApr2011
AUTHORISATION
C¢üPÀÈvÀ C¢üPÁgÀ
(To be filled & signed by the Claimant)
(ºÀPÀÄÌzÁgÀ¤AzÀ vÀÄA© ¸À» ªÀiÁqÀ®àqÀ¨ÉÃPÀÄ)
Life Insurance Policy No.(s) ____________________________________
I, Mr. / Mrs / Ms. ______________________________________ (name of the claimant),
_______________________________________________ (relation with Life Assured) hereby give my co nsent 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.
Date:
Yours faithfully
Place:
(Signature of Claimant)
fêÀ«ªÀiÁ ¥Á°¹ ¸ÀASÉå (UÀ¼ÀÄ) ____________________________________
£Á£ÀÄ, ²æÃ./²æêÀÄw./PÀĪÀiÁj _________________________ (ºÀPÀÄÌzÁgÀ£À ºÉ¸ÀgÀÄ), _________________________ ªÉÄ.C«ªÁ fêÀ«ªÀiÁ
PÀA¥À¤ EArAiÀiÁ °«ÄmÉqï, ªÀÄvÀÄÛ/CxÀªÁ CzÀgÀ ¥Àæw¤¢üAiÀÄÄ J¯Áè PÉ®¸ÀzÀ/ªÉÊzÀåQÃAiÀÄ/D¸ÀàvÉæAiÀÄ zÁR¯ÉUÀ¼ÀÄ/DgÀPÀëPÀ zÁR¯ÉUÀ¼ÀÄ/ EvÀgÀ zÁR¯ÉUÀ¼ÀÆ
(£ÀPÀ®Ä¥ÀæwUÀ¼À£ÉÆß¼ÀUÉÆAqÀÄ) £À£Àß aQvÉìUÉ ¸ÀA§AzsÀ¥ÀlÖ ªÀiÁ»w / PÀA¥À¤¬ÄAzÀ ¥Á°¹AiÀÄ£ÀÄß £À£ÀUÉ ¤ÃqÀªÀ ªÀÄÄ£Àß ¥ÀqÉzÀÄPÉÆAqÀAxÁ GzÉÆåÃUÀzÀ «ªÀgÀ
ºÁUÀÆ EvÀgÀ fêÀ«ªÀiÁ PÀA¥À¤UÀ½AzÀ £Á£ÀÄ F M¥ÀàAzÀPÉÌ §gÀĪÀ ªÉÆzÀ¯Éà CxÀªÁ £ÀAvÀgÀ ¥ÀqÉzÀÄPÉÆArgÀĪÀ C¹ÜvÀézÀ°ègÀĪÀ ¥Á°¹UÀ¼À «ªÀgÀUÀ¼À£ÀÄß
¥ÀqÉzÀÄPÉƼÀÀÄzÉAzÀÄ F ªÀÄÆ®PÀ M¦àPÉÆArzÉÝãÉ.
¢£ÁAPÀ:
¸ÀܼÀ:
vÀªÀÄä «zsÉÃAiÀÄ,
(ºÀPÀÄÌzÁgÀ£À ¸À»)
Claim/DCF/Ver1.0/1stApr2011
Contact details of the claimant:
ºÀPÀÄÌzÁgÀ£À ¸ÀA¥ÀPÀ𠫪ÀgÀUÀ¼ÀÄ:
Address: «¼Á¸Àt:
________________________
________________________
________________________
________________________
Pin: ¦£Ï:
____________________
Landline: STD Code _______ No. _______________
¹ÜgÀªÁtÂ: J¸ïnr PÉÆÃqï __________ ¸ÀASÉå. _______________
Mobile: ªÉƨÉʯï: __________________
Email id: EªÉÄÃ¯ï «¼Á¸À: ………………………………..
Claim/DCF/Ver1.0/1stApr2011
NEFT Mandate Form: Direct Transfer of Claim amount to your Bank Account
J£ïEJ¥sïn DzÉñÀzÀ Cfð: ºÀQÌ£À ªÉÆvÀÛªÀ£ÀÄß ¤ªÀÄä SÁvÉUÉ £ÉÃgÀªÁV ªÀUÁð¬Ä¸À¯ÉÆøÀÌgÀ
Mandatory: Copy of cancelled cheque bearing the below mentioned account number along with this form .
PÀqÁØAiÀÄ: PɼÀUÉ w½¹zÀ SÁvÉ ¸ÀASÉåAiÀÄ£ÀÄß ºÉÆA¢gÀĪÀ gÀzÀÄÝUÉƽ¹zÀ ZÉPï ¥ÀæwAiÀÄ£ÀÄß F CfðAiÉÆA¢UÉ ®UÀwÛ¸À¨ÉÃPÀÄ.
To, UÉ,
AVIVA life Insurance Company India Limited, C«ªÁ fêÀ«ªÀiÁ PÀA¥À¤ EArAiÀiÁ °«ÄmÉqï,
Sub: E-Payments vide NEFT «µÀAiÀÄ: J£ïEJ¥sïn ªÀÄÆ®PÀ E-¥ÁªÀw
I/We request and authorize you to effect E-payment vide NEFT mode to my/our Bank account as per the details given below:
F PɼÀUÉ ¤ÃrgÀĪÀ «ªÀgÀUÀ¼À ªÉÄÃgÉUÉ £À£Àß/£ÀªÀÄä ¨ÁåAPï SÁvÉUÉ J£ïEJ¥sïn ªÀÄÆ®PÀ E-¥ÁªÀwAiÀÄ£ÀÄß ªÀiÁqÀ®Ä £Á£ÀÄ/£ÁªÀÅ PÉýPÉƼÀÄîvÉÛÃ£É ªÀÄvÀÄÛ
C¢üPÀÈvÀ C¢üPÁgÀ ¤ÃqÀÄvÉÛãÉ:
Full name of the Claimant:
First Name
ºÀPÀÄÌzÁgÀ£À ¥ÀÆwð ºÉ¸ÀgÀÄ:
Middle Name
ªÉÆzÀ® ºÉ¸ÀgÀÄ
ªÀÄzsÀåzÀ ºÉ¸ÀgÀÄ
Surname
PÀÄ®£ÁªÀÄ
Full name of the Bank Account Holder as appearing in the Account: ¨ÁåAPï SÁvÉAiÀÄ°ègÀĪÀAvÉAiÉÄà SÁvÉzÁgÀ£À ¥ÀÆwð ºÉ¸ÀgÀÄ:
First Name
Middle Name
ªÉÆzÀ® ºÉ¸ÀgÀÄ
ªÀÄzsÀåzÀ ºÉ¸ÀgÀÄ
Surname
PÀÄ®£ÁªÀÄ
Bank Account No. ¨ÁåAPï SÁvÉAiÀÄ ¸ÀASÉå:
Bank Name: ¨ÁåAPï ºÉ¸ÀgÀÄ:
Bank Address ( Including State, City, Pin Code):
¨ÁåAPï «¼Á¸À (gÁdå, £ÀUÀgÀ, ¦£ï PÉÆÃqïUÀ¼À£ÉÆß¼ÀUÉÆAqÀÄ):
Bank Branch contact persons’ names and Tele nos with STD Code:
¨ÁåAPï ±ÁSÉAiÀÄ°è ¸ÀA¥ÀQð¸À¨ÉÃPÁzÀ ªÀåQÛUÀ¼À ºÉ¸ÀgÀÄUÀ¼ÀÄ ªÀÄvÀÄÛ J¸ïnr PÉÆÃqï£ÉÆA¢UÉ zÀÆgÀªÁt ¸ÀASÉåUÀ¼ÀÄ:
Account Type: SÁvÉAiÀÄ «zsÀ:
Saving Account G½vÁAiÀÄ SÁvÉ:
Current Account
ZÁ°Û SÁvÉ:
Bank Branch IFSC Code No. ( Mandatory for NEFT):
¨ÁåAPï ±ÁSÉAiÀÄ LJ¥sïJ¸ï¹ PÉÆÃqï ¸ÀASÉå. (J£ïEJ¥sïnUÉ PÀqÁØAiÀÄ):
Bank Branch MICR Code: ¨ÁåAPï SÁvÉAiÀÄ JªÀiïL¹Dgï PÉÆÃqï:
I/We confirm that information provided above is correct and any consequences due to any mistake in above will be borne by me.
ªÉÄÃ¯É ¤ÃrzÀ ªÀiÁ»wAiÀÄÄ ¸ÀjAiÀiÁVzÉ ªÀÄvÀÄÛ EzÀgÀ°è AiÀiÁªÀÅzÉà «ZÁgÀ C¸ÀªÀÄ¥ÀðPÀªÁVzÀÄÝ GAmÁUÀĪÀ ¥ÀjuÁªÀĪÀ£ÀÄß £À¤ßAzÀ JzÀÄj¸À¯ÁUÀÄvÀÛzÉAiÉÄAzÀÄ F
ªÀÄÆ®PÀ £Á£ÀÄ/£ÁªÀÅ RavÀ¥Àr¸ÀÄvÉÛãÉ/ªÉ.
Thanking You, ZsÀ£ÀåªÁzÀUÀ¼ÉÆA¢UÉ,
Name & Signature of the Claimant:
ºÀPÀÄÌzÁgÀ£À ºÉ¸ÀgÀÄ & ¸À»:
Bank Verification: ¨ÁåAPï£À ¸ÀvÁå¥À£É:
We confirm that we are enabled for receiving for NEFT credits and we further confirm that the account number of
the…………………………………………… and the signature of the authorised signatory and the IFSC and MICR codes of our branch
mentioned above are correct.
J£ïEJ¥sïnAiÀÄ ªÀiË®åUÀ¼À£ÀÄß ¥ÀqÉAiÀÄĪÀ ¸Ë®¨sÀåªÀ£ÀÄß ºÉÆA¢zÉÝÃªÉ JAzÀÄ £ÁªÀÅ RavÀ¥Àr¸ÀÄvÉÛÃªÉ ªÀÄvÀÄÛ .......................................................... gÀ SÁvÉAiÀÄ
¸ÀASÉå ªÀÄvÀÄÛ C¢üPÀÈvÀ C¢üPÁgÀ ¸À» ªÀÄvÀÄÛ ªÉÄÃ¯É ¤ÃrgÀĪÀ £ÀªÀÄä ±ÁSÉAiÀÄ LJ¥sïJ¸ï¹ ªÀÄvÀÄÛ JªÀiïL¹Dgï PÉÆÃqïUÀ¼ÀÄ ¸ÀjAiÀiÁVªÉAiÉÄAzÀÆ £ÁªÀÅ RavÀ¥Àr¸ÀÄvÉÛêÉ.
Bank verification Stamp with branch address and Signature of the Banker:
¨ÁåAPï£ÀªÀgÀ ¸À» ªÀÄvÀÄÛ ±ÁSÉAiÀÄ «¼Á¸ÀzÉÆA¢UÉ ¨ÁåAPï ¸ÀvÁå¥À£Á ªÀÄÄzÉæ:
Name of the Signing authority:
¸À» ªÀiÁqÀĪÀ C¢üPÁjAiÀÄ ºÉ¸ÀgÀÄ:
Claim/DCF/Ver1.0/1stApr2011
ACKNOWLEDGEMENT SLIP
¹éÃPÀÈw aÃn
Policy No.: ¥Á°¹ ¸ÀASÉå:
Name of Life Assured: ºÀPÀÄÌzÁgÀ£À ºÉ¸ÀgÀÄ: …………………………………………………………………………….......…..
Service Request ID: ¸ÉêÁ ªÀÄ£À« Lr/UÀÄgÀÄvÀÄ ¸ÀASÉå: ……………………………………………………………………………...........…..
Documents Submitted: Please Tick
¸À°è¸À®àlÖ zÁR¯ÉUÀ¼ÀÄ: zÀAiÀÄ«lÄÖ UÀÄgÀÄvÀÄ ªÀiÁr
Attested Death Claim Form and Signed by the Claimant
¸ÀéAiÀÄA-zÀÈrüÃPÀÈvÀ ºÀPÀĄ̈ÁzsÀåvÁ Cfð ªÀÄvÀÄÛ ºÀPÀÄÌzÁgÀ¤AzÀ ¸À» ªÀiÁqÀ®ànÖzÉ
Original Death Certificate or attested copy thereof issued by Municipal Authorities
ªÀÄÆ® ªÀÄgÀt ¥ÀvÀæ ªÀÄvÀÄÛ £ÀUÀgÀ¸À¨sÉAiÀÄ C¢üPÀÈvÀ C¢üPÁjUÀ½AzÀ ¸ÀéAiÀÄA-zÀÈrüÃPÀÈvÀUÉÆAqÀÄ «vÀj¹zÀ ¥ÀvÀæzÀ ¥Àæw
Original Policy Document (s)
ªÀÄÆ® ¥Á°¹ ¥ÀvÀæ(UÀ¼ÀÄ)
Copy of Claimant’s current address proof
ºÀPÀÄÌzÁgÀ£À ¥Àæ¸ÀÄÛvÀ «¼Á¸À ¥ÀÄgÁªÉAiÀÄ ¥Àæw
Copy of Claimant’s Photo Id proof which establishes relationship with life assured
«ªÉÄUÉƼÀUÉÆAqÀ ¸ÀzÀ¸Àå£ÉÆA¢V£À ¸ÀA§AzsÀªÀ£ÀÄß zÀÈqsÀUÉƽ¸À®Ä ºÀPÀÄÌzÁgÀ£À ¨sÁªÀavÀæ UÀÄgÀÄvÀÄ ¥ÀÄgÁªÉAiÀÄ ¥Àæw
Copy of signed cancelled cheque (Mandatory) with NEFT Mandate Form
J£ïEJ¥sïn DzÉñÀzÀ CfðAiÉÆA¢UÉ ¸À» ªÀiÁr gÀzÀÄÝUÉƽ¹zÀ ZÉPï£À ¥Àæw (PÀqÁØAiÀÄ)
Last Medical Attendant Report
PÉÆ£ÉAiÀÄ ªÉÊzÀåQÃAiÀÄ ¸ÉêÁzÁgÀ¤AzÀ ¤ÃqÀ®àlÖ ªÀgÀ¢
Medical Records
ªÉÊzÀåQÃAiÀÄ zÁR¯ÉUÀ¼ÀÄ
Employer’s Questionnaire
MqÉAiÀÄ£À ¥Àæ±ÉÆßÃvÀÛgÀUÀ¼ÀÄ
Copy of First Information Report (FIR)
ªÉÆzÀ® ªÀiÁ»w ªÀgÀ¢ (J¥sïLDgï)AiÀÄ ¥Àæw
Copy of Post Mortem Report, Viscera Report
ªÀÄgÀuÉÆÃvÀÛgÀ ±ÀªÀ¥ÀjÃPÉëAiÀÄ ªÀgÀ¢, DAvÀæ ªÀgÀ¢
Inquest Panchanama
«ZÁgÀuÁ ¥ÀAZÀ£ÁªÉÄ
Policy Final Investigation Report
¥Á°¹AiÀÄ PÉÆ£Éà «ZÁgÀuÁ ªÀgÀ¢
Newspaper Cutting
ªÁvÁð¥ÀwæPÁ ªÀgÀ¢AiÀÄ vÀÄAqÀÄ
BRANCH STAMP WITH
RECEIPT DATE:
¹éÃPÀÈw ¢£ÁAPÀzÉÆA¢UÉ ¨ÁåAPï£À ªÀÄÄzÉæ:
Processed by (Name & Signature):
PÁAiÀÄðUÀvÀUÉƽ¹zÀªÀgÀÄ (ºÉ¸ÀgÀÄ & ¸À»):
Claim/DCF/Ver1.0/1stApr2011
Claim Contact Points
Mailing Address:
For any urgent queries contact:
For any Claim related queries
please write to:
Aviva Life Insurance Company India Ltd.
rd
3 Floor. Aviva Towers, Sector ‐43,
Opposite DLF Golf Course,
Gurgaon‐122003
Haryana
Customer service Helpline Number
1800‐180‐22‐66 (Toll Free)
[email protected]
0124‐2709046
ºÀPÀĄ̈ÁzsÀåvÉUÉ ¸ÀA¥ÀPÀð ¸ÁÜ£ÀUÀ¼ÀÄ:
CAZÉ «¼Á¸À:
AiÀiÁªÀÅzÉà vÀÄvÀÄð ¥Àæ±ÉßUÀ½zÀÝ°è ¸ÀA¥ÀQð¹:
C«ªÁ fêÀ«ªÀiÁ PÀA¥À¤ EArAiÀiÁ °«ÄmÉqï,
3£Éà ªÀĺÀr, C«ªÁ lªÀ¸ïð, 43£Éà ¸ÉPÀÖgï,
rJ¯ïJ¥sï UÉÆïïá ªÉÄÊzÁ£ÀzÀ JzÀÄgÀÄ,
UÀÄgïUÁAªï 122003
UÁæºÀPÀ ¸ÉêÁ ¸ÀºÁAiÀÄ ¸ÀASÉå:
1800-180-22-66(±ÀÄ®Ì gÀ»vÀ)
AiÀiÁªÀÅzÉà ¥Àæ±ÉßUÀ½zÀÝ°è zÀAiÀÄ«lÄÖ
E°èUÉ §gɬÄj:
[email protected]
0124-2709046
A Joint Venture between Dabur Invest Corp. & Aviva Interna onal Holdings Limited
Aviva Life Insurance Company India Ltd
Head Office: Aviva Tower, Sector Road, Opp. DLF Golf Course, DLF Ph‐ V, Sector 43, Gurgaon‐122003. Haryana India.
Registered Office: 2nd Floor, Prakashdeep Building, 7 Tolstoy Marg, New Delhi‐110001. India
qÁ§gï E£Éé¸ïÖ PÁ¥ïð ºÁUÀÆ C«ªÁ EAlgï£Áå±À£À¯ï ºÉÆðØAUïì °«ÄmÉqï £ÀqÀÄ«£À MAzÀÄ ¸ÀºÀAiÉÆÃUÀ
C«ªÁ fêÀ«ªÀiÁ PÀA¥À¤ EArAiÀiÁ °«ÄmÉqï¡
PÉÃAzÀæ PÀbÉÃj: C«ªÁ UÉÆÃ¥ÀÄgÀ/lªÀgï, ¸ÉPÀÖgï gÀ¸ÉÛ, rJ¯ïJ¥sï UÉÆïïá ªÉÄÊzÁ£ÀzÀ JzÀÄgÀÄ, rJ¯ïJ¥sï WÀlÖ 5, ¸ÉPÀÖgï 43, UÀÄgïUÁAªï-122003. ºÀjAiÀiÁt, ¨sÁgÀvÀ
£ÉÆÃAzÁ¬ÄvÀ PÀbÉÃj: 2£Éà ªÀĺÀr, ¥ÀæPÁ±ï¢Ã¥ï PÀlÖqÀ, 7 mÁ¯ï¸ÁÖAiÀiï gÀ¸ÉÛ, £ÀªÀ zɺÀ° - 110001, ¨sÁgÀvÀ
Tel/ zÀÆgÀªÁtÂ:+91 (0) 124 270 9000 Fax/ ¥sÁåPïì: +91 (0) 124 257 1210.
www.avivaindia.com Email/ E-ªÉÄïï :[email protected]