Group Life Insurance Claim Form
1. Insured Member Details
Full Name
Member ID / Policy No.
Date of Birth
Gender
Contact Number
Address
2. Employer / Group Details
Employer / Group Name
Group/Policy Number
3. Claim Details
Date of Death
Cause of Death
Place of Death
Additional Details
4. Beneficiary Details
Beneficiary Name
Relationship to Insured
Beneficiary Contact
Beneficiary Address
5. Declaration
I hereby declare that the information given above is true and complete.
Signature
Date