Claimant’s Statement (Death Claim)

The Claimant : (To be completed by person / institution legally entitled for the Benefit)

Group Policy Number

Group Policy Holder Name

Name of the beneficiary and

relationship to the Insured Member

The Insured Member:

Full Name

Place of death

Date and time of death

Gender Male Female Age at death

Address at death

Cause of death

Last date at work

Name and address of employer just

prior to death

In case of death due to illness :

When and where did the Insured

Member give first indication of falling ill

Date and type of illness

Treatment given

Name, Address & Phone No. of the

Doctor consulted the insured during last
illness

Name & Address of the Hospital where

the insured undergone treatment for the
last illness

Name and address of the Doctors consulted during last 3 years prior to death

Date of Consultation Name & Address of Doctor’s Clinic Reason for Consultation

Chennai:+91-44-24315831/32 Bangalore:+91-80-26438638 Hyderabad:+91-40-23398480/23398481 Kochi : +91-484-2343686 Trivandrum:+91-471-3095214/246/248/2533331

Thrichur :+91-487-2444822 / 823 Coimbatore :+91-422-5368100 / 200 / 300 Delhi :+91-11-23321443/ 448 Kolkata :+91-33-22178823/ 24 Mumbai :+91-22 24954771

Toll Free: 1-600-44-6969 Write to us at metlifeindia@metlife.com

 Claimant’s Statement (Death Claim)

In case of death due to accident :

Date and time of accident Place of accident

Details of accident

Address of Police Station to which the

accident was reported

Name & Address of the Hospital from

which the Post-mortem was conducted

*Beneficiary/ies of the Insured Member,

Relationship with insured, % of shares
and to whom the claim amount is
payable for the GTL policy

*Beneficiary/ies of the Insured Member,

Relationship with insured, % of shares
and to whom the claim amount is
payable for the EDLI policy

*If the Nominee is a minor please

state the name & address of guardian
along with Nominee Bank account
details

*Name & Address of the Bank with

Account number of Beneficiary/ies

Declaration and Authorization:

I/We, the above named claimant/s, do solemnly declare that the foregoing statements are true and agree that furnishing this form, or any
other form supplemental thereto, by the Company, shall not constitute an admission by it that there was any insurance in force on the life
in question or a waiver of any rights or defence.

Notwithstanding, any law, custom or usage, prohibiting the furnishing of secret information obtained during the medical treatment /
investigation of member. I/We hereby authorize any doctor or other person, or any hospital, sanatorium, medical professional, hospital
or other medical care institution, insurance support organization, pharmacy, governmental agency, insurance company, employer,
benefit plan administrator, accountant or financial advisor or other institute to provide to MetLife India Insurance Company Pvt.Ltd, any
of it offices, or Court of Law, or any investigative agency or independent administrator acting on its behalf, information concerning
employment, finances or insurance, advice, care or treatment provided to Insured Member, or any information that may be required
concerning the health of the Insured Member including information relating to mental illness, use of drugs, use of alcohol, HIV(AIDS)

Chennai:+91-44-24315831/32 Bangalore:+91-80-26438638 Hyderabad:+91-40-23398480/23398481 Kochi : +91-484-2343686 Trivandrum:+91-471-3095214/246/248/2533331

Thrichur :+91-487-2444822 / 823 Coimbatore :+91-422-5368100 / 200 / 300 Delhi :+91-11-23321443/ 448 Kolkata :+91-33-22178823/ 24 Mumbai :+91-22 24954771

Toll Free: 1-600-44-6969 Write to us at metlifeindia@metlife.com

 Claimant’s Statement (Death Claim)
and / or sexually transmitted diseases. A Photostat copy of this authorisation shall be considered as effective and valid as the original.

The Policy Holder shall hold all benefits received under this policy UPON TRUST for the benefit of the person(s) to whom the benefits
are payable in accordance with the Rules and the Policy Holder shall have no interest in the same.

Authorised Signatory of Group Policy Holder

Signature of Claimant: Signature :

Name : Name :
Date : Date :

[Company Seal]

Chennai:+91-44-24315831/32 Bangalore:+91-80-26438638 Hyderabad:+91-40-23398480/23398481 Kochi : +91-484-2343686 Trivandrum:+91-471-3095214/246/248/2533331

Thrichur :+91-487-2444822 / 823 Coimbatore :+91-422-5368100 / 200 / 300 Delhi :+91-11-23321443/ 448 Kolkata :+91-33-22178823/ 24 Mumbai :+91-22 24954771

Toll Free: 1-600-44-6969 Write to us at metlifeindia@metlife.com