INDIVIDUAL DEATH CLAIM FORM

For Official Use Only

Branch Name: Branch Code:

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

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

SECTION A*
POLICY DETAILS
09120007170
Policy Number(s): _______________________________________

SECTION B*
DETAILS OF LIFE ASSURED (LA)

Name of Life Assured: . Mr. Ms. F I R S SHAIK

T MOHAMMEDM ABDUL
I D D RAHIMAN
L E L A S T

Father's Name: F I SHAIK

R S T JABBAR M I D D L E L A S T

Date of Death D 25/10/2024

D M M Y Y Y Y

Place of Death Hospital Clinic . Residence Office Other (Please specify)________________________

Family Doctor: Name Dr. SUJAY SUDA Registration No Contact No

Last treated/attended Doctor: Name None Registration No Contact No

Last Employer details (If applicable):

Name of the Company Name of contact person Contact No

Nature of Death Medical

, Natural Accident Murder Suicide

Cause of Death Natural

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

Hypertension Diabetes Heart disease Liver disease
Kidney disease Cancer Other
Smoking Tobacco Drugs If yes, Duration of Consumption & Quantity Consumed

CL/C/Ver 1.0/2022 Page 1 of 5

 Other Insurance details: (Life/Mediclaim/Health)
Policy No. Company Name Sum Assured Status (Active/Lapsed/Applied/Matured)

DETAILS OF CLAIMANT
Claimant Name: , Mr. Ms. F I SHAIK
R S T MOHAMMED ABDUL
M I DIMTIAZ
D L E L A S T

Date of Birth: 04/02/1990

D D M M Y Y Y Y

Address: 20/1476
F I R S mecleans
T road , near genius school
L A S T

Kotamitta
B U I
nellore
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: 524001

Contact No.:
9550628913
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: [email protected] / [email protected]

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: AIOPI3202L Or Form 60

Politically exposed person: Yes , No

US Person: Yes , No (If Yes, please fill FATCA / CRS certification)

In case of children's plans, if beneficiary is a major, please provide beneficiary's account details
Bank Account No. : 99980105882729 IFSC Code (11Characters)

Account Holder Name: Shaik mohammed abdul imtiaz

Bank Name & Branch: Federal bank

Account Type , Savings Current NRO NRE Account Holder’s Name
MICR Code (9 Characters)

IFSC: FDRL0001668 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

Blank space for companies to input product specific payout methods

CL/C/Ver 1.0/2022 Page 2 of 5

 SECTION C*
DECLARATION AND AUTHORISATION
• I here 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 Canara HSBC 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 Canara HSBC Life Insurance Company Limited Life 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.

DECLARATION TO BE MADE BY A THIRD PERSON

The Policyholder 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 Policyholder in_____________________________________language
English and have
truthfully recorded the answers provided to me. I further declare that the Policyholder has signed/affixed his/her thumb impression in my
presence.

Name of the Declarant: Shaik Mohammed abdul imtiaz

Address: 20/1476 mecleans road near genius scholl kotamitta nellore 524001

SIGN HERE
Date: 02/12/2024
D D M M Y Y Y Y

Place Nellore Signature of Claimant

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:[email protected]

CL/C/Ver 1.0/2022 Page 3 of 5

 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. Canara HSBC 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)
, , Valid Passport
,
Claimant's PAN CARD 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 Valid Driving License

Any other Central/State Govt. issued ID Bank Passbook with stamped photograph (not more than 6 months old)
*I voluntarily provide my consent to use my Aadhar to conduct identity check towards KYC compliance by Canara HSBC Life Insurance Company Limited

CL/C/Ver 1.0/2022 Page 4 of 5

 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 Canara HSBC Life
Insurance Company Limited Life.
• 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.

Canara HSBC Life Insurance Company Limited

(formerly known as Canara HSBC Oriental Bank of Commerce Life Insurance Company Limited) IRDAI Regn. No. 136
Head Office Address: 139 P, Sector 44, Gurugram – 122003, Haryana, India
Registered Office Address: 8th Floor, Unit No. 808 - 814, Ambadeep Building, Plot No.14, Kasturba Gandhi Marg, New Delhi - 110001
Corporate Identity No: U66010DL2007PLC248825

Call us at 1800-103-0003/1800-180-0003/1800-891-0003 SMS at 7039004411

E-mail us at [email protected] Visit our website at www.canarahsbclife.com

BEWARE OF SPURIOUS / FRAUD PHONE CALLS: 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.

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

Canara HSBC Life Insurance Company Limited

(formerly known as Canara HSBC Oriental Bank of Commerce Life Insurance Company Limited) IRDAI Regn. No. 136
Head Office Address: 139 P, Sector 44, Gurugram – 122003, Haryana, India
Registered Office Address: 8th Floor, Unit No. 808 - 814, Ambadeep Building, Plot No.14, Kasturba Gandhi Marg, New Delhi - 110001
Corporate Identity No: U66010DL2007PLC248825

Call us at 1800-103-0003/1800-180-0003/1800-891-0003 SMS at 7039004411

E-mail us at [email protected] Visit our website at www.canarahsbclife.com

BEWARE OF SPURIOUS / FRAUD PHONE CALLS: 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.

CL/C/Ver 1.0/2022 Page 5 of 5