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

Attending Physician Statement – Form B

Name of the deceased / patient

Address of the deceased

Age Gender
Male  Female 

Hospital/ Indoor patient Number

Date of Death Time of death

Place of Death (if hospital or institution, please

give the name & address)

Date of first Consultation/ first Diagnosis:

What were the symptoms / illness/ disease?

Duration of symptoms/illness/disease

Which investigations/ tests were performed:

What was the diagnosis

Interval between onset and death __________Yrs _____________ Months ____________ Days

Antecedent Conditions related or contributing

but not related to the cause of death

Was the patient informed of your findings?

Yes  No 

Have you treated the deceased during 5 years,

prior to final illness? Yes  No  If “Yes” details:

Are you aware if deceased consulted any other

doctor/ hospital apart from you? Yes  No  If “Yes” details:

If death was due to unnatural reasons, please

specify & provide death summary Inquest held? Yes  No 

Autopsy done? Yes  No 

Has this patient, to your knowledge, used

tobacco products, alcohol, narcotics? Yes  No  Don’t Know  Details: ___________________________________

DECLARATION:
The above statements are true and complete to the best of my knowledge and belief and as per the records maintained by hospital/ clinic:
Signature of the Physician

Name of the Physician

Qualification of the Physician

Regd. No. of the Physician
Contact No.: Physician/ Hospital
Email id of the Physician
Date: Physician/ Hospital Seal

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Contact our Toll Free No. 1800-425-6969 for any queries or write to us at indiaservice@pnbmetlife.co.in
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