Joint Life Insurance Death Claim Form
1. Policy Details
Policy Number
Date of Commencement
Sum Assured
Plan/Type
2. Deceased Life Assured Details
Full Name
Date of Birth
Date of Death
Cause of Death
Place of Death
Relationship to Claimant
3. Surviving Life Assured Details
Full Name
Date of Birth
Contact Number
Email Address
4. Nominee/Claimant Details
Full Name
Address
Contact Number
Email Address
Relationship to Deceased
5. Bank Account Details for Claim Payment
Bank Name
Account Number
IFSC Code
Account Holder Name
6. Declaration
I hereby declare that the information provided is true and correct to the best of my knowledge.
Signature of Surviving Life Assured
Signature of Claimant/Nominee
Date: