Critical Illness Claim Form

POLICY NUMBER
Important instructions:
• The submission of the filled-up claim form, along with the required mandatory documents, is not to be construed as an admission of
liabilities of our Company under the policy. No agent/intermediary has been or is authorized to admit any liabilities on behalf of the
Company.
• Early submission of this form along with the required mandatory documents, as provided below, will enable us to process your claim
faster. PNB MetLife shall not be responsible for any delay in the processing of the claim on account of submission of incomplete claim
form and/or non-submission of the mandatory documents.
• This form is to be filled in completely in BLOCK letters.
• Please Counter-sign where amendments/alterations are made in the form.
• Witness signature of a Gazetted Officer/Notary Public/Magistrate or Person of local standing is mandatory.
• Forms & all requirements to be submitted at the nearest branch office of PNB MetLife or the address mentioned above.

Section A: DETAILS OF THE LIFE INSURED

Name: ______________________________________________________________________ Age:

Address (Current Residential Address):

City ____________________________ Pin Code ___________________________ State

Contact Number: Landline ___________________________________ Mobile
E-mail Address: ___________________________________________ PAN No./ Form 60: _________________________________________
*Aadhaar No: X X X X X X X X *Only last 4 digits to be mentioned.

Section B: MEDICAL HISTORY OF LIFE INSURED

Name of Illness/Disease/Injury Sustained:

Symptoms:
Duration of symptoms: __________________________ Date of Diagnosis:
When were these symptoms first evident/occurred:
Date and Time of Admission _______________________ Date and Time of Discharge
Name of hospital:
Have you ever had the similar condition in past:  Yes  No (If “yes,” provide details)

Nature of Illness and Habits Date of diagnosis of Illness

 Hypertension  Diabetes  Asthma  Heart  Cancer

 Tuberculosis Other……………………………………

 Smoking  Alcohol  Tobacco  Drugs

If yes, Duration of Consumption______________________________________ & Quantity Consumed______________________

CRITICAL ILLNESS ACKNOWLEDGEMENT SLIP

Policy number(s) _____________________, _____________________, _____________________, _____________________,
Name of claimant __ Company Seal
Branch name & code __ & Stamp with
Date: Employee name & Code _______________________ Date and time
Documents:  Original Policy Document  Claimant’s photo identity proof  Family physician certificate
Submitted:  Cancelled cheque / Copy of bank passbook)  Attending physician certificate
 PAN Card/ Form 60  Medical Documents (if any)  All past medical records for any treatment taken
 Complete medical records for diagnosis and treatment of the illness diagnosed i.e., all test/investigation
reports, discharge summary, indoor case paper

This acknowledgement slip should not be construed as acceptance of the claim. The Company reserves its right to call additional documents,
information and any further requirements necessary in order to decide on processing of the claim.
Version 3.5/Nov’22
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Information about the Critical Illness (Please tick the illness diagnosed)

 Heart attack  Cancer  CABG (Coronary Artery Bypass Surgery)

 Stroke  Apallic Syndrome  Benign Brain Tumor
 Blindness  Brain Surgery  Coma
 End Stage Liver Disease  Heart Valve Surgery  Major Head Trauma
 Angioplasty  Major Organ Transplant  Paralysis
 Aplastic Anemia  Cardiomyopathy  Deafness
 Parkinson’s Disease  Poliomyelitis  SLE with Lupus Nephritis
 Primary Pulmonary Hypertension  Muscular Dystrophy  Multiple Sclerosis
 Motor Neuron Disease  Medullary Cystic Disease  Loss of Speech
 Kidney Failure  Alzheimer’s Disease  Surgery to Aorta
 Major Burns  Terminal Illness  Loss of Limbs
 Loss of Independent Existence  Chronic Lung Disease

Section C: PAYMENT – NEFT

Bank Account no:

Name of bank:
IFSC code:

Section D: DECLARATION & AUTHORIZATION

I do hereby declare that all the above statements are true and complete and that nothing has been suppressed or with - held from my side. I understand that
in furnishing claim form PNB MetLife has not admitted liability or waived any of its rights under the policy. I hereby authorize the physician or hospital who
has attended upon or examined or treated me for any ailment or illness to divulge any knowledge or information or furnish the records regarding my state of
health which he/they may have acquired whether before or after the policy was issued by PNB MetLife.

I/We hereby further consent, and authorize, PNB MetLife to use and disclose any of the personal and sensitive information of mine/our collected or available
with PNB MetLife (whether contained in this statement or obtained otherwise) which may include KYC documents to any individual / organisation / entity
associated or affiliated with or engaged by PNB MetLife, including reinsurers, claim investigative agencies, vendors and industry association / federations, for
the purpose of processing this claim and/or for providing subsequent service.

Signature/Left Thumb impression _______________________________________________________ Date _______________________________________

Declaration by the person filling in the Critical Illness Claim form. (in case the Critical Illness Claim form is filled up / signed in a language different from
that of application form)
I hereby declare that I have fully explained the contents of the Critical Illness Claim form to the claimant in the language understood by him/her. The same
have been fully understood by him/her and the replies have been recorded as per the information provided by the claimant and the replies have been read
out to, fully understood and confirmed the claimant.
The content of the form and document have been fully explained to me and that I have fully understood the content mentioned herein and its significance
for the proposed Claim
__________________ _____________________ ________________________________ _____________________________________
Date Place Signature of Declarant/ Witness Signature / Left thumb Impression
Claimant/ Nominee
Name of Declarant/ Witness: ____________________________ Address of Declarant/ Witness: ______________________________________
Contact No. of Declarant/ Witness: _______________________ Claimant relation with Declarant/ Witness: _____________________________
Date: _______________________________________________ Place: ___________________________________________________________

Mandatory Documents to be submitted along with this form:

• Doctor’s Certificate (From the family physician or treating doctor) preferably in the standardized PNB MetLife format
• Discharge Summary confirming the surgery undergone
• All past medical records for any treatment taken
• Cancelled cheque / Copy of bank passbook
• PAN Card/ Form 60 of the life assured
• Current address proof
• Photo identity proof
• Hospital Cash Benefit Claim Form to be attested by concerned doctor
• Authorization letter from the claimant in case the claim intimation is received through third party for claims received at the Branch/
GPH
Note: Please mask first 8 digits of Aadhaar number if Aadhaar Card is submitted as KYC proof with the request

PNB MetLife India Insurance Company Limited

Registered office: Unit No. 701, 702 & 703, 7th Floor, West Wing, Raheja Towers, 26/27 M G Road, Bangalore -560001. IRDA of India Registration number 117.
Version 3.5/Nov’22
CI No. U66010KA2001PLC028883, Call us Toll-free at 1-800-425-6969, Website: www.pnbmetlife.com, Email: [email protected] or write to us at 1st
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Floor, Techniplex -1, Techniplex Complex, Off Veer Savarkar Flyover, Goregaon (West), Mumbai – 400062. Phone: +91-22-41790000, Fax: +91-22-41790203