GROUP INSURANCE CLAIM FORM
FOR CI CLAIMS
COMPLETE IN DUPLICATE – RETAIN COPY FOR YOUR RECORDS
(All sections to be completed)
A. PLAN DETAILS
(1)
Name of Plan ___________________________________________
(2)
Policy Number
(3)
Policy holder Name ________________________________________________________________________________________
Address ________________________________________________________________________________________
Pin Code Phone Number
B. MEMBER DETAILS
(1)
Name of Member ___________________________________________________________________________________________
(Title) (Surname) (First Name) (Middle Name)
Residential Address ________________________________________________________________________________________
Pin Code _________________ Phone Number _____________________________________________
(2)
Date of Birth
D
D
M
M
Y
Y
(6)
Member ID.
(3)
Date of Joining
D
D
M
M
Y
Y
(7)
Loan Amount
(4)
Cover commenced date
D
D
M
M
Y
Y
(8)
Annual salary
(5)
D
D
M
M
Y
Y
(9)
Cover Amount
C. CLAIM EVENT DETAILS (FOR DEATH CLAIMS ONLY)
(1)
Date of Diagnosis of CI
D D M M Y Y
(3)
Nature of CI _______________________________________________________________________________________
(4)
Name of the Hospital where treatment was taken
E. BENEFIT DETAILS
(1)
Benefit Payable to
Policy holder
Beneficiary**
Member
(2)
Bank Account Details (mandatory)
Name of Account Holder _____________________________________________________ Account No _____________________
Name of Bank and Branch ____________________________________________________________________________________
(3)
Address to which cheque and confirmation of payment should be sent:
Contact Person ________________________________________________________________________________________
E-mail Address ________________________________________________________________________________________
Postal Address ________________________________________________________________________________________
_________________________________________________________________________________________
** Beneficiary details form to accompany this form
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Remarks _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
DECLARATION AND AUTHORITY TO PAY CLAIM
I/We the undersigned, in my/our capacity as (designation)………………………………………………………………..and duly authorised to make this
declaration, hereby declare:
i. That the person whose illness gave rise to this claim is in fact ill and was in fact a legitimate member of the Plan on the date of diagnosis of the illness
ii. That he/she joined employment / the Group on (date) …………….. and he/she was actively at work / in Good Health on the date of commencement of
cover.
iii. That in the event the claim is admitted, the payment of the proceeds due in respect of the above member in terms of the afore-mentioned Plan shall
represent the full and final discharge of Kotak Mahindra Life Insurance Company Ltd’s liability in respect of that member under the said Plan.
Signed at: ………………………………………………………………………. this………….day of…………………………. 20…..
Designation …………………………………..
Name …………………………………………
Signature ……………………………………...
Please attach to this form Primary documentation required for death claims:
Proof of membership (e.g. Certified copy of the latest Pay slip, certified copy of membership card etc)
All case hospital papers & history papers.
(The above mentioned documents are indicative and additional documents may be called for where necessary)
FOR Kotak Mahindra Life Insurance Company Ltd. OFFICE USE ONLY
I confirm that I have checked the details on this form and have satisfied myself that they are correct.
Name …………………………………………………………
Designation …………………………………………………..
Signature …………………………………………………….
Contact No ……………………………………………………
E-mail ID ……………………………………………………..
OFFICIAL
COMPANY
STAMP
Kotak Mahindra Life Insurance Company Ltd. (Formerly known as Kotak Mahindra Old Mutual Life Insurance Ltd.)
Regn. No.:107, CIN : U66030MH2000PLC128503, Regd. Office: 2nd Floor, Plot # C- 12, G- Block, BKC, Bandra (E), Mumbai - 400 051.
Website: http://insurance.kotak.com I Email: clientservicedesk@kotak.com
| Toll Free No:1800 209 8800.
Trade Logo displayed above belongs to Kotak Mahindra Bank Limited and is used by Kotak Mahindra Life Insurance Company Ltd. under license.
For any queries please write to the below Address : Claims Department | Kotak Mahindra Life Insurance Co Ltd, Building No 21, Infinity IT Park, Off Western
Express Highway, Gen. A. K. Vaidya Marg, Malad (E), Mumbai - 400097.
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