HANDOUT-DEATH CLAIM. Our mailing address is as follows. Claims Department, Aviva Life Insurance Company India Limited,

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1 HANDOUT-DEATH CLAIM KIND ATTENTION: CLAIMANT We deeply regret the sad demise of your loved one. We assure you of our support throughout the claims process to help and assist you to complete the formalities required for the same. We would like to inform you that we would require the following documents in order to settle your claim at the earliest. Request you to go through the documents mentioned below carefully, along with the specific instructions mentioned, which will help you in submission of these at the earliest. 1. Death Claim Form - Please provide answers to each point and details wherever required. This form has to be filled and duly signed by the nominee. In case there is more than one nominee then we would require a separate claim form, from each nominee. Claims Form has to be attested by the person(s) as mentioned and specified in the Claim form. 2. Original Policy Documents and Schedule - Please submit the Policy Documents and schedule which were provided at the time of commencement of this policy. 3. Lost Original Policy Documents and Schedule In case the policy documents & Schedule is lost, please intimate us assigning the reason and explaining the circumstances in which it was lost. An indemnity on Rs.100/- stamp paper duly executed, signed, witnessed and notarized needs to be submitted along with attested ID proof and address proof of the deceased Life Insured. 4. Death Certificate - Proof of death should be in the form of original certified extract from Government Office wherever records of births and deaths taking place are maintained with authority to issue death certificate. This would include Municipality, District Board, Block Development Office or Village panchayat. In case of copy of death certificate is submitted, it should be attested by gazette officer. 5. Last Medical Attendant's Report - To be filled and attested by the Doctor / Hospital who has treated the Life Assured last or has provided the treatment prior to death of Life Assured in case any treatment has been taken. 6. Death/ Discharge Summary Issued by the hospital where Life assured had taken last treatment (in case any treatment has been taken). 7. Other hospital papers Diagnosis and treatment Records of Life Assured for any illness (in case any diagnostic tests conducted or treatment has been taken). 8. Hospital Authority Letter - As per Terms & conditions of the policy, we would require this authorization from you. 9. FIR,Police Inquest Report and Final Police Inquest report -To be obtained from Police Authorities-In case FIR has been lodged and Police Inquest has been done or is in process. 10. Post Mortem Report - To be obtained from Police Authorities, in case Post Mortem has been conducted. 11. Age Proof of the Life Assured - Kindly submit the age proof of Life Assured, if not submitted at the time of Proposal. 12. NEFT Mandate Form - To make direct transfer of claim payment to your account, please provide NEFT Mandate Form along with copy of cancelled cheque bearing IFSC code, Bank account number and name of the claimant. If the cancelled cheque copy does not contain the information asked for, please provide the passbook copy along with cancelled cheque copy. 13. Current Address Proof of the nominee Please provide relevant address proof for the address mentioned in the claim form. 14. Identification proof of the nominee - Photo ID proof issued by Government Authorities 15. Contact number of the nominee - Please provide the correct Mobile/ Landline number Should you have any queries or clarifications during the process of submission of the above documents, you can write to us at claims@avivaindia.com. Alternatively you contact our Customer Service Helpline number OR (Monday to Saturday, 8AM to 8PM). Our mailing address is as follows Claims Department, Aviva Life Insurance Company India Limited, Aviva Tower, Sector Road, Opp. Golf Course, DLF phase-v, Sector 43, Gurgaon Tele No , Fax

2 DEATH CLAIM FORM (DCF) CLAIMS DOCUMENT CHECKLIST (CDCL) Life Assured Name: Policy No.: Please submit this form along with the requirements mentioned below at the nearest branch or address mentioned overleaf for faster processing of claim Documents from 6 to12 not required in Pension Policies (other than Pension Elite) Please note that all documents needs to be self attested. Claim Document Please tick the documents submitted 1. Original Death Certificate or attested copy thereof issued by Municipal Authorities. 2. Original Policy Document (s). 3. Claim Form duly filled, signed by claimant and duly attested by an authorized person as mentioned in claim form 4. Copy of Claimant s current address proof 5. Authorization Form duly filled, signed by claimant 6. Copy of Claimant s Photo Id proof which establishes relationship with life assured 7. Copy of signed cancelled cheque (Mandatory) with NEFT Mandate Form 8.Last Medical Attendant s Report 9. Copies of all past Medical Records, Diagnostic Test Reports, Discharge/ Death summary 10.Employer s questionnaire In case of accidental/ unnatural death, in addition to the above, the following documents are required 11.Copy of First Information Report ( FIR) 12.Copy of Post Mortem Report, Viscera Report 13.Inquest Panchanama 14.Policy Final Investigation Report 15.Newspaper cutting (If any)

3 Aviva Life Insurance Company India Ltd. 3nd Floor, Aviva Towers, Sector 43, Opposite DLF Golf Course, Gurgaon Haryana India Tel. +91(0) Fax +91(0) Registered Office: 2nd Floor Prakashdeep Building, 7, Tolstoy Marg New Delhi India DEATH CLAIM FORM (DCF) 1. Policy No.: 2. Name of Deceased Life Assured: First Name Middle Name Surname 3. Name of Claimant Section I -Details of the Claimant First Name Middle Name Surname 4. Current Residential Address (Current Address should match with Mobile no.: Address proof provided) Phone no. with STD Code: City: Pin Code: Id: 5. Relationship with Life Insured 6. Title under which the claim is submitted (Please Tick) PAN No: 1. Nominee 2. Appointee 3. Survivor 4. Assignee 5. Trustee 6. Beneficiary 7. HUF 7. Bank Account Details: Please find enclosed NEFT Mandate Form Mandatory: (Please attach a copy of signed cancelled cheque along with this form) 8. If there is any other claim underlying the policy, please tick the appropriate box and submit respective claim form for the same. HCB Critical Illness Permanent Total Disability Date of Birth Section II Details of Deceased Life Insured

4 Date of Death Time of Death a.m./p.m. Place o Death Cause of Death If Place of Death is outside India: Yes No Was the deceased buried or cremated abroad? If yes, enclose a copy of the burial/ cremation permit. Employment Details: Name of the Employer s /Business Name Address : City & Pin Code : Mobile or Phone no. Exact nature of Job/ Business Death due to Accident: Date of Accident Time of Accident a.m./ p.m. Place of Accident Please provide duly attested copy of documents mentioned in the checklist for accidental death (From 8 to 12)(Mandatory) Death due to Illness: Date of First Complaint of Symptoms Name of the Doctor/ Hospital or Clinic who declared death Name of the Doctor/ Hospital or Clinic consulted during last illness Address, Contact No Date of Consultation Nature of Illness Name of the Doctor/Hospital who was consulted for present illness or any other illness during the last three years. Name of the Doctor/ Hospital or Clinic Address, Contact No Date of Consultation Nature of Illness

5 Policy no. Sum Assured Name of Insurance Company Date of Commencement Claim Status Rider Coverage (if any) Declaration: In connection with claim under policy no. for Rs. on the life of Life Insured, I Claimant, do hereby declare that the statement made herein above I true in each and every respect. *Countersigned By: Date Signature of the Claimant: Date Designation Address Address Certified that the contents of this form were explained to the declarant in vernacular and he/she has affixed is/ her signature/ thumb impression hereto after fully understanding the same. Signature Name of the Witness: Designation: Address: * This statement must be countersigned by any of the following: (1) an Advocate (2) A Bank Manager (3) A Medical Practitioner (4) A Gazette Officer (5) A Head Master/ Principal of a local Govt. High School (6) A magistrate (7) President Of A Village Panchayat or Local Board (8) Sales Manager of Aviva Life Insurance Company India Limited

6 AUTHORISATION (To be filled & signed by the Claimant) Life Insurance Policy No.(s) I, Mr. / Mrs / Ms. (name of the claimant), (relation with Life Assured) hereby give my consent to M/s Aviva Life Insurance Company India Limited, and / or its representative to obtain all employment / medical / hospital records / police records / other records (including photocopies) / information pertaining to the treatment / occupation of the deceased Life Assured which he/ they may have acquired whether before or after the policy as well as details from other Life Insurance Companies regarding any existing policies which he / they may have sourced before or after the initiation of this contract. Date: Yours faithfully Place: (Signature of Claimant) Contact details of the claimant: Address: Pin: Landline: STD Code No. Mobile: id:..

7 NEFT Mandate Form: Direct Transfer of Claim amount to your Bank Account Mandatory: Copy of cancelled cheque bearing the below mentioned account number along with this form. To, AVIVA life Insurance Company India Limited, Sub: E-Payments vide NEFT I/We request and authorize you to effect E-payment vide NEFT mode to my/our Bank account as per the details given below: Full name of the Claimant: First Name Middle Name Surname Full name of the Bank Account Holder as appearing in the Account: First Name Middle Name Surname Bank Account No. Bank Name: Bank Address ( Including State, City, Pin Code): Bank Branch contact persons names and Tele nos with STD Code: Account Type: Saving Account Current Account Bank Branch IFSC Code No. ( Mandatory for NEFT): Bank Branch MICR Code: I/We confirm that information provided above is correct and any consequences due to any mistake in above will be borne by me. Thanking You, Name & Signature of the Claimant: Bank Verification: We confirm that we are enabled for receiving for NEFT credits and we further confirm that the account number of the and the signature of the authorised signatory and the IFSC and MICR codes of our branch mentioned above are correct. Bank verification Stamp with branch address and Signature of the Banker Name of the Signing authority

8 Last Medical Attendant's Report Policy No- Date- I. General Information 1 a) Name of Life Assured b). 2. Were you the Life Assured s usual Doctor? If yes, Please give details how long have you known the deceased 3. Date of Death 4. Immediate cause of Death.. 5. Underlying cause of Death. 6. Duration of Ailment.. 7. Was the deceased referred to you by another Doctor or Hospital? If yes, please give details: Name of Doctor/Hospital. Address of Doctor/Hospital. II. Information About the illness and accident: 1. Details of Illness/Accident 2. Date of First Consultation. 3. Date of Diagnosis 4. What were the Life Assureds presenting complaints. 5. History of Present Illness.. 6. Any other past medical illness 7. Did the deceased suffer from any other ailment other than the ailment that eventually led to death? Yes No If yes, give brief particular of it with duration and treatment rendered III. Other Information 1. Name and address of Hospital were Life assured was admitted 2. Date of Admission.. 3. Date of Discharge/Death 4. Admission no./c.r. No./IP No 5. Details of treatment rendered.. IV. Investigations Conducted Was any Investigation conducted on the life Assured: Type of Investigation Conducted Results/Readings

9 Diagnosis made after investigation- Name of Illness/Diseases: Name, qualifications & Address of the Doctor by who the above Diagnosis were made: Treatments Given: V. Had the Life Assured been ever admitted on earlier Occasion to this hospital or had the medical As In-Pateint As Out-Patinet From Dates Complaints / Symptoms To Treatment Given Name,Adress & Telephone of the Treating Docotor VII. Habits of the Life Assured: a) Were the Life Assured 's habits Sober & Temperate? YES / NO b) Did he have any additction such as Smokin, Drinking etc.? YES/ NO. If Yes, Pls befief about the quantity of the consumption: c) Have you any reason to suppose or to supect that the disease was in this case caused or aggravated by When & for which other disease/ailment/illness did you treat the life Assured in the last 3 years before this? Any other information, which you consider would be useful for processing the claim under the Policy. Signature of the Medical Attendant Name & Registration No. Stamp & Address Date: Place:

10 ACKNOWLEDGEMENT SLIP Policy No.: Name of Life Assured.. Service Request ID:... Documents Submitted: Please Tick Attested Death Claim Form and Signed by the Claimant Original Death Certificate or attested copy thereof issued by Municipal Authorities Original Policy Document (s) Copy of Claimant s current address proof Copy of Claimant s Photo Id proof which establishes relationship with life assured Copy of signed cancelled cheque (Mandatory) with NEFT Mandate Form Last Medical Attendant Report Medical Records Employer s Questionnaire Copy of First Information Report (FIR) Copy of Post Mortem Report, Viscera Report Inquest Panchanama Policy Final Investigation Report Newspaper Cutting BRANCH STAMP WITH RECEIPT DATE: Processed by (Name & Signature): Claim Contact Points Mailing Address: For any urgent queries contact: For any Claim related queries please write to: Aviva Life Insurance Company India Ltd. Customer service Helpline Number claims@avivaindia.com Aviva Towers, Sector-43, (Toll Free) Opposite DLF Golf Course, Gurgaon Haryana