CLAIM INTIMATION FORM (FORM A) PAGE | 1

Death Claim

Important – Mandatory Documents to be submitted along with Claim Intimation Form

1. Original policy document

2. Address Proof and Identity Proof of the Claimant – Self Attested

3. Copy of Death Certificate of the Life Assured

4. Cancelled cheque with pre-printed name of the Claimant / Self attested Bank Statement / Pass Book attested by Bank

Critical Illness Dismemberment

H H M M:

D M M Y Y Y YDDate of Birth:

D M M Y Y Y YD

D M M Y Y Y YD

Date of Birth of Claimant/Nominee

Date of Death:

Cause of Death:

If cause of Death is due to Accident provide date of Accident:

Was death reported to police (If YES, copy of FIR attached): YES NO

Occupation:

IRDA REGN. NO. 142

DETAILS OF DEATH OF THE LIFE ASSURED

BANK ACCOUNT DETAILS OF CLAIMANT

CLAIM DISBURSAL OPTION IN CASE OF ANNUITY PLAN (APPLICABLE ONLY FOR DHRUV TARA PLAN)

DETAILS OF LIFE ASSURED

DETAILS OF CLAIMANT:

Name of Life Assured

Name of Claimant:

Relation with Deceased (Insured):

Appointee Name (if Claimant/Nominee is minor):

Policy Number

Flat/Plot No.:

Flat/Plot No.:

Building Name:

Building Name:

Road:

Road:

Landmark:

Landmark:

City/District:

City/District:

Pin Code:

Pin Code:

State:

State:

Place of Death Time of Death

Contact No.:

Contact No.:

Email ID:

Email ID:

(AM/PM)

Bank Name:

rd rdI wish to commute 1/3 of the Fund Value or Sum Assured to be paid to me in Lumpsum and 2/3 of the Fund Value or Sum Assured should be

drawn in favour of SUD Life Insurance Co. Ltd. OR

(Please write name of the Insurance Company from where you want to purchase annuity in the space give above) as full and final settlement.

Branch Address:

Bank A/C No.: Type of Account

IFSC Code:

Nominee Name as per Account

MICR Code:

SUD/May-2014/CI-A-Form/Ver1

Registered Office: Bank of India, Star House, C-5, “G” Block, Bandra – Kurla Complex, Bandra (East), Mumbai – 400 051thCorporate Office: Raghuleela Arcade, 11 Floor , I.T. Park, Sector 30 A, Opp Vashi Railway Station, Vashi, Navi Mumbai – 400 703.

Customer Care: Toll Free No: 18002008833 or Land line No: 022 39546300 (Charges apply) Timing: 8:00 am to 8:00 pm (Mon – Sat) Website: www.sudlife.in | C.I.No.-U66010MH2007PLC174472.

FOR BANK/BRANCH USE ONLY

Employee Name:

Employee Signature:

Signature & Branch Date/Time Stamp:

CLAIMANT’S DECLARATION

I hereby declare that the answers given above are true in all respect. Notwithstanding the provisions of any law. I hereby authorize the company to

contact any Physician or Hospital to enquire about the health of the deceased, who treated him / her in the last illness of the deceased. I will not

hold Star Union Dai-ichi Life Insurance Company Ltd. responsible in cases of non-credit to my bank account or if the transaction is delayed or not

effected at all for reasons of incomplete / incorrect information.

Signature of Declarant: Date:Place:

CLAIM INTIMATION FORM (FORM A) PAGE | 2 IRDA REGN. NO. 142

Address of Claimant / Nominee

Address of Witness:

Contact No.:

Name of Claimant / Nominee

Name of Witness:

Signature/Thumb Impressionof Claimant / Nominee

Signature/Thumb Impression of Witness:

DECLARATION TO BE MADE BY A THIRD PARTY IF:

I, Mr./Ms./Dr.

The policyholder/ has affixed thumb impression OR the policyholder/nominee has signed in vernacular OR the policyholder/nominee has not filled the Application.nominee

Address

(month/years); do declare that I have explained the contents of this form to the policyholder/nominee

in his/her policyholder/nominee language and have truthfully recorded the answers provided by him/her. I further declare that the has affixed his signature/thumb

impression in my presence.

having known the for a period ofpolicyholder/nominee

SUD/May-2014/CI-A-Form/Ver1

Registered Office: Bank of India, Star House, C-5, “G” Block, Bandra – Kurla Complex, Bandra (East), Mumbai – 400 051thCorporate Office: Raghuleela Arcade, 11 Floor , I.T. Park, Sector 30 A, Opp Vashi Railway Station, Vashi, Navi Mumbai – 400 703.

Customer Care: Toll Free No: 18002008833 or Land line No: 022 39546300 (Charges apply) Timing: 8:00 am to 8:00 pm (Mon – Sat) Website: www.sudlife.in | C.I.No.-U66010MH2007PLC174472.