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, Karnataka. IRDA of India Registration number 117.
CI No. U66010KA2001PLC028883, Call us Toll-free at 1-800-425-6969, Website: www.pnbmetlife.com, Email: indiaservice@pnbmetlife.co.in or write to us at 1st Floor,
Techniplex -1, Techniplex Complex, Off Veer Savarkar Flyover, Goregaon (West), Mumbai – 400062. Phone: +91-22-41790000, Fax: +91-22-41790203

Claimant Application for Death` Claim – Form A

This form to be duly filled by the Nominee OR Assignee or Legal Heir (as applicable) in BLOCK Letters.
All the answers to be complete, clear and correct. Use “Not applicable” (N/A) as appropriate instead of leaving it blank. Please
tick the appropriate box wherever applicable.
Please submit this form along with the requirements mentioned below at the PNB MetLife nearest branch or address mentioned
below. Please use an additional sheet to provide additional details if and when required.
CLAIMANT SHOULD SIGN ON ALL PAGES and Counter – Sign where corrections /alterations are made in the form.
Documents to be submitted along with this form~ Non Accidental Death Accidental Death
(~PNB MetLife reserves the right to call for any additional documents/ (Illness/Natural) ( Accident / Murder/ Suicide)
clarifications/ evidences apart from the following, if required.) Required Yes/ No Required Yes/ No
Original Policy Document Yes Yes
Death Certificate – Original OR Notarized copy of Death Certifi cate Yes Yes
Photo ID Proof* of Nominee/ Appointee/Legal Heirs (Attested by MetLife Ops Yes Yes
Official, or Gazetted officer or Notary public)
*PAN Card/ Passport/ Voter Id Card/ Driving license/ Bank Pass-book/ Any other ID proof issued
by Government Authorities etc.
Current Address Proof** of Nominee/Appointee/Legal Heirs (Attested by Yes Yes
PNB MetLife Ops Official, or Gazetted officer or Notary public)
**Passport/ Latest Electricity Bill/ Latest Telephone bill – Landline/ Latest Gas booking bill/ Bank
Pass- book/ Voter ID Card/ Driving License etc.
Last Attending Physician Statement (Form B) Yes If Available
Family Doctor Certificate Yes N/A
All medical /hospitals records like Admission Note, Test Records, Discharge Yes Yes
Summary, Death Summary, etc.
Copies of First Information Report( FIR) to police (Attested by issuing If available Yes
authority/Notary)
Copies of Post Mortem Report (Attested by issuing Authority/ Notary) If Available Yes
Obituary /News Paper Cutting If Available Yes

1. POLICY NUMBER/S………………………………………………………………………………………………………………………………………………………………………………….

2. PERSONAL DETAILS OF THE LIFE INSURED

Name of the Insured:

Late………………………………………………………………………..………………………………………………………………………………………………….. Date of Birth OR

Age at time of Death ……………………………… Marital Status at time of death: Single  Married  Divorced  Widowed 

Address: …………………………………………………………………………………………………………………………..…………………………………………………………………………...

City: ……………………………………………………State………………………………..……………Pin Code: …………………Phone/Mobile: ……………………………………….

3. OCCUPATION DETAILS OF THE LIFE INSURED

Employed  Business  Others  …………………………………………………………………………………………………………………………………………………….

Designation at Work……………………………………………………………………………………………………………………………………………………………………………………..

Office / Business Address: ……………………………………………………………………………………………………………………………………………………………… ……………

City: …………………………………………………………………Telephone No/ Mobile No ………………………………………………………………………………………………..

Office/ Business Email Id: ……………………………………………………………………………………………………………………………………………………………………………

4. DEATH DETAILS OF THE LIFE INSURED

Claimant’s Signature /Thumb Impression…………………………
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 Claimant Application for Death` Claim – Form A

Date of Death __ __/ __ __/ __ __ __ __ Time of Death………………… (AM/ PM) Date of Cremation/ Burial: __ __/ __ __/ __ __ __ __

Place of Death: Home  Hospital  Other Place* (please Specify) ………………………………………………………………………………………………….

(*If death has occurred abroad, please attach a separate sheet with following details: Details of Passport of Life Insured (number, date of issue); Date of the life
insured last leaving India; Details of when and how the body was transported back to India, if applicable.)

Cause of Death: Accident  Murder  Suicide  Negligence  Illness  Others (please specify)…………………………………………………

Specify Type of Illness………………………………………………………………………………………………………………………………………………………………………………..

5. DETAILS OF LAST ATTENDING DOCTOR WHO TREATED THE LIFE INSURED

Name of The Doctor: ……………………………………………………………………………..…………………………………………………………………………………………………

Name of The Hospital: ……………………………………………………………………………………………………………………………………………………………………………..

Disease / Condition Treated For ……………………………………………………………………………………………………………………………………………………………….

Date of Consultation/ Treatment Commenced on __ __/ __ __/ __ __ __ __ (DD/MM/YYYY)

Address of Doctor/ Hospital: ……………………………………………………………………………………………..…………………………………………………………………….

Doctor/ Hospital Telephone No/ Mobile No ………………………………………. Email ID……………………………………………………………………………………..

6. DETAILS OF FAMILY DOCTOR OF LIFE INSURED

Name of The Doctor: ……………………………………………………………………………..…………………………………………………………………………………………………

Name of The Hospital: ……………………………………………………………………………………………………………………………………………………………………………..

Disease / Condition Treated For ……………………………………………………………………………………………………………………………………………………………….

Date of Consultation/ Treatment Commenced on __ __/ __ __/ __ __ __ __ Address of Doctor/ Hospital: …………………………………………….

…………………………………………………………….. Contact No ………………………………………. Email ID……………………………………………………………………..

7. DETAILS OF ACCIDENT/ UNNATURAL DEATH (LIKE SUICIDE/ MURDER/ RIOTS/ TERRORISTS ATTACK ETC.)

Date of Accident / Incident __ __/ __ __/ __ __ __ __ (DD/MM/YYYY) Time of Accident/ Incident: …………………………………………………

Place of Accident /

Incident……………………………………………………………………………………………………………………………………………………………………. Brief Details of

Accident/ Incident …………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………………………

8. NAME AND ADDRESS OF POLICE STATION TO WHICH THE ACCIDENT /INCIDENT WAS INFORMED

Name of Police Station: …………………………………………………….. Contact Number of Police Station: …………………………… FIR No: …………………….

Address of Police Station: …………………………………………………………………………………………………………………………..…………………………………………….

Claimant’s Signature /Thumb

Impression…………………………

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 Claimant Application for Death` Claim – Form A
9. NAME AND ADDRESS OF THE HOSPITAL WHERE THE POST MORTEM WAS PERFORMED

Name of The Hospital: ……………………………………………………………..………………………………………………………………… PMR No: …………………………

Address: …………………………………………………………………………………………………………………………..……………………………………………………………………

Telephone No/ Mobile No: ………………………………………. Email ID…………………………………………………………………………………………....................

10. NAMES, PLACES AND CONTAT DETAILS OF ALL DOCTORS / HOSPITALS WHERE THE LIFE INSURED WAS TREATED WITHIN THE
LAST 5 YEARS PRECEEDING THE DEATH

Name of Doctor/ Hospital Place and Contact Details Disease /Condition Treated For Treatment Dates (From- To)

11. DETAILS OF OTHER LIFE INSURANCE POLICIES OF THE LIFE INSURED

Name of Life Insurance Company Policy Number/s Policy Commencement Date Coverage Amount (Rs.) Claim Submitted?

12. DETAILS OF THE CLAIMANT (POLICY OWNER/ NOMINEE/ ASSINEE/ LEGAL HEIR)

Name of The Claimant: ……………………………………………………..………………………………………………………………………………………………………………….

Relationship With Life Insured…………………..... …………………….. Claimant’s Date of Birth OR Current Age: ……………………………………………

Claimant’s Address*: ……………………………………………………………………………… ……………………………………………………………………………………………

City: …………………………………………………………………………. State: .……………………………..…………………………………… PIN Code: ……………………….

(*This address shall match with the address as mentioned in the address proof that you submit to us along with this form.)

Telephone No/ Mobile No ………………………………………. Email ID…………………………………………………………………………………………………………..

In Which Capacity Are You Claiming? Nominee  Assignee  Legal Heir*  Policy Owner 
(*Please attach a notarized OR gazetted officer attested Legal Heir certificate issued by competent authority OR Succession certificate Issued by a Competent Court,
establishing your relationship with the Life Insured.)

If the Claim is on an ANNUITY Product, Please Tick The Appropriate Option of Benefit Required*: Lump sum  Annuity 
(*Subject to applicable Terms & Conditions of the Policy.)

Preferred Mode of Claim Payout: By Cheque  By Electronic Transfer* 

(*If electronic mode of transfer is chosen, NEFT form (Electronic Funds Transfer Mandate Form) should be duly filled-in and attached to this form compulsorily.)

Bank Account Number of Claimant: ……………………………………………………………………………………………………………………………………………………….

Name of The Bank …………………………………………………………………………………………………………………………………………………………………………………

Address of The Bank: …………………………………………………………………………………………………………………………………………………………………………….

Claimant’s Signature /Thumb
Impression…………………………

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 Claimant Application for Death` Claim – Form A
Declaration and Authorization:

I/We, the above named Claimant(s), do solemnly declare that the above answers and statements are true in all respects, and I/ We
further agree that in furnishing claim form PNB MetLife has not admitted any liability or waived any of its rights.

I/We hereby authorize the physicians or hospitals, medical centers, who has attended upon or examined or treated the aforesaid
deceased person/insured for any ailment or illness or other Insurance Companies which issued policies to the aforesaid deceased person/
insured, present/ past employers or business associates of the life insured, Birth and Death registrar, Diagnostic centers wherein the life
insured underwent personal/ official/ insurance related medical tests, to divulge or share any knowledge or information or documents
regarding the deceased’s state of health or other details which he/they may have acquired whether before or after the policy was issued
by PNB MetLife. A Photo Copy of this authorization shall be considered as effective and valid as the Original.

Signature*/ Thumb impression of Claimant ………………………………………………….…………………… Date …………………………………

*Note: Signature in Indian languages must have their English translation written beneath. Further the claimant signing in the Indian
language should give a declaration in the Indian language that he/she has understood the contents of the above form fully and properly as
explained to him/her in the language understood by him/her by an English knowing person who shall also sign to the effect that he/she
has fully explained the contents of the above form to claimant.

Place for declaration in Indian Language:

Signature of Witness**: ………………………………………………

** (Witness should be by a Gazetted Officer/Notary Public/Magistrate/A Bank Manager/ President of Village Panchayat/ Head
Postmaster/ Headmaster of a High School / Person of local standing)

Name of Witness: ……………………………………………………………………………………………………………………………………………………………

Address of Witness: ………………………………………………………………………………………………………………………………………………………..

Date ……..........

Official Seal of the Witness:

For Office Use Only

Branch to Affix the date and time stamp here with details of OSV/ASV with | HO, Claims to Affix the date seal here.
signature of Brach Service Associate. | (Time, if received directly.)
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TALISMA Ticket No. _________________ |

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