{"id":121,"title":"INDIVIDUAL DEATH CLAIM FORM","purpose":"claim","insurer":{"slug":"canara-hsbc-life-insurance","name":"Canara HSBC Life Insurance Company Limited"},"source_pdf":"https://www.canarahsbclife.com/content/dam/chli/pdf/document-component/individual-claims/english/death_claim_form_c.pdf","sha256":"34cb3770acee3d13230864914bba45a0559851bcc7a96a4c0c3c4f0b55ca53ff","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is used by the claimant to file a death claim under an individual life insurance policy with Canara HSBC Life Insurance Company Limited.","notes":["The form should be filled by the claimant only; guardian/appointee may fill if claimant is a minor.","Claims under multiple policies can be registered with a single form providing all policy numbers.","Separate forms are required for multiple claimants.","Sign the claim form as per usual signature.","No fee or commission should be paid to anyone for claim processing.","Ensure address, phone numbers, and email ID are current and active for correspondence.","Asterisk (*) indicates mandatory information.","Submit copies of documents and present originals at claim submission.","The insurer reserves the right to request additional documents if required.","Beware of spurious/fraud phone calls; report suspicious calls to the company email claims.unit@canarahsbclife.in.","Attach a cancelled personalized cheque or latest bank statement/passbook with account number and IFSC for NEFT mandate.","NEFT mandate will override previous mandates for all policies with the insurer.","Payouts may be held if NEFT mandate is incomplete or fails; intimation will be sent.","For NRE account refunds, submit bank statement or confirmation letter as evidence of premium payment through NRE account.","For proportionate payouts, provide two NEFT mandates for NRE and non-NRE accounts."],"title":"INDIVIDUAL DEATH CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"SECTION A: POLICY DETAILS","fields":[{"help":"Enter all applicable policy numbers for which the claim is being made.","type":"text","label":"Policy Number(s):","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"SECTION B: DETAILS OF LIFE ASSURED (LA)","fields":[{"help":"Select the place where the death occurred; specify if 'Other'.","type":"choice","label":"Place of Death","options":["Hospital","Clinic","Residence","Office","Other (Please specify)"],"required":true,"pdf_field":""},{"help":"Enter the date of death in DD/MM/YYYY format.","type":"date","label":"Date of Death","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of the father of the life assured.","type":"text","label":"Father's Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of the deceased life assured.","type":"text","label":"Name of Life Assured:","options":[],"required":true,"pdf_field":""},{"help":"Select the appropriate title of the life assured.","type":"choice","label":"Mr. / Ms.","options":["Mr.","Ms."],"required":true,"pdf_field":""},{"help":"Enter name of the company if applicable.","type":"text","label":"Name of the Company","options":[],"required":false,"pdf_field":""},{"help":"Enter contact person name at the company if applicable.","type":"text","label":"Name of contact person","options":[],"required":false,"pdf_field":""},{"help":"Enter contact number of the company or contact person.","type":"phone","label":"Contact No","options":[],"required":false,"pdf_field":""},{"help":"Provide last employer details if applicable.","type":"text","label":"Last Employer details (If applicable):","options":[],"required":false,"pdf_field":""},{"help":"Select the nature of death.","type":"choice","label":"Nature of Death","options":["Medical","Natural","Accident","Murder","Suicide"],"required":true,"pdf_field":""},{"help":"Describe the cause of death.","type":"text","label":"Cause of Death","options":[],"required":true,"pdf_field":""},{"help":"Enter name of family doctor if known.","type":"text","label":"Family Doctor: Name","options":[],"required":false,"pdf_field":""},{"help":"Enter registration number of family doctor.","type":"text","label":"Registration No","options":[],"required":false,"pdf_field":""},{"help":"Enter contact number of family doctor.","type":"phone","label":"Contact No","options":[],"required":false,"pdf_field":""},{"help":"Enter name of last treating doctor.","type":"text","label":"Last treated/attended Doctor: Name","options":[],"required":false,"pdf_field":""},{"help":"Enter registration number of last treating doctor.","type":"text","label":"Registration No","options":[],"required":false,"pdf_field":""},{"help":"Enter contact number of last treating doctor.","type":"phone","label":"Contact No","options":[],"required":false,"pdf_field":""},{"help":"Tick if the insured had hypertension.","type":"checkbox","label":"Hypertension","options":["Hypertension"],"required":false,"pdf_field":""},{"help":"Tick if the insured had diabetes.","type":"checkbox","label":"Diabetes","options":["Diabetes"],"required":false,"pdf_field":""},{"help":"Tick if the insured had heart disease.","type":"checkbox","label":"Heart disease","options":["Heart disease"],"required":false,"pdf_field":""},{"help":"Tick if the insured had liver disease.","type":"checkbox","label":"Liver disease","options":["Liver disease"],"required":false,"pdf_field":""},{"help":"Tick if the insured had kidney disease.","type":"checkbox","label":"Kidney disease","options":["Kidney disease"],"required":false,"pdf_field":""},{"help":"Tick if the insured had cancer.","type":"checkbox","label":"Cancer","options":["Cancer"],"required":false,"pdf_field":""},{"help":"Specify any other illness.","type":"text","label":"Other","options":[],"required":false,"pdf_field":""},{"help":"Tick if the insured smoked.","type":"checkbox","label":"Smoking","options":["Smoking"],"required":false,"pdf_field":""},{"help":"Tick if the insured used tobacco.","type":"checkbox","label":"Tobacco","options":["Tobacco"],"required":false,"pdf_field":""},{"help":"Provide details if the insured consumed drugs including duration and quantity.","type":"text","label":"Drugs    If yes, Duration of Consumption & Quantity Consumed","options":[],"required":false,"pdf_field":""},{"help":"Describe the nature of illness and habits of the insured.","type":"text","label":"Nature of Illness and Habit of the insured","options":[],"required":false,"pdf_field":""},{"help":"Enter date of diagnosis in DD/MM/YYYY format.","type":"date","label":"Date of diagnosis of illness","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details (for beneficiaries)","fields":[{"help":"Select the type of bank account.","type":"choice","label":"Account Type","options":["Savings","Current","NRO","NRE"],"required":false,"pdf_field":""},{"help":"Enter the 11-character IFSC code of the bank branch.","type":"text","label":"IFSC Code (11Characters)","options":[],"required":false,"pdf_field":""},{"help":"Enter the name of the bank account holder.","type":"text","label":"Account Holder’s Name","options":[],"required":false,"pdf_field":""},{"help":"Enter the 9-character MICR code of the bank branch.","type":"text","label":"MICR Code (9 Characters)","options":[],"required":false,"pdf_field":""},{"help":"Enter the bank account number.","type":"text","label":"Bank Account No.","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Policy and Other Insurance Details","fields":[{"help":"Enter policy number for other policies if any.","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Enter company name for other insurance policies.","type":"text","label":"Company Name","options":[],"required":false,"pdf_field":""},{"help":"Enter sum assured for other insurance policies.","type":"amount","label":"Sum Assured","options":[],"required":false,"pdf_field":""},{"help":"Select the status of other insurance policies.","type":"choice","label":"Status (Active/Lapsed/Applied/Matured)","options":["Active","Lapsed","Applied","Matured"],"required":false,"pdf_field":""},{"help":"Provide details of other insurance policies if any.","type":"text","label":"Other Insurance details: (Life/Mediclaim/Health)","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"DETAILS OF CLAIMANT","fields":[{"help":"Select claimant's title.","type":"choice","label":"Mr. / Ms.","options":["Mr.","Ms."],"required":true,"pdf_field":""},{"help":"Provide PAN details or submit Form 60.","type":"text","label":"Claimant's PAN details: Or Form 60","options":[],"required":true,"pdf_field":""},{"help":"Indicate if claimant is a politically exposed person.","type":"yes-no","label":"Politically exposed person: Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter full name of the claimant.","type":"text","label":"Claimant Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter full address of the claimant.","type":"text","label":"Address:","options":[],"required":true,"pdf_field":""},{"help":"Enter postal pincode.","type":"number","label":"Pincode:","options":[],"required":true,"pdf_field":""},{"help":"Enter claimant's contact number.","type":"phone","label":"Contact No.:","options":[],"required":true,"pdf_field":""},{"help":"Enter claimant's email address.","type":"email","label":"Office & / or Personal Email ID:","options":[],"required":false,"pdf_field":""},{"help":"Select relation to the life assured; specify if 'Others'.","type":"choice","label":"Relation with the Life Assured:","options":["Spouse","Children","Parents","Others"],"required":true,"pdf_field":""},{"help":"Enter claimant's date of birth in DD/MM/YYYY format.","type":"date","label":"Date of Birth:","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"SECTION C: DECLARATION AND AUTHORISATION","fields":[{"help":"Sign the form as per usual signature.","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing.","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing in DD/MM/YYYY format.","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration by Third Person (if applicable)","fields":[{"help":"Enter full name of the person declaring on behalf of policyholder.","type":"text","label":"Name of the Declarant:","options":[],"required":true,"pdf_field":""},{"help":"Enter address of the declarant.","type":"text","label":"Address:","options":[],"required":true,"pdf_field":""}],"filled_by":"third person"},{"title":"C. LIST OF VALID IDENTITY & ADDRESS PROOFS","fields":[{"help":"Tick one valid photo identity proof submitted. Aadhar Card consent is voluntary for KYC.","type":"choice","label":"PHOTO IDENTIFY PROOF (ANY ONE)","options":["Aadhar Card*","Valid Driving License","Voter ID Card","Bank Passbook with stamped photograph (not more than 6 months old)","Claimant's PAN CARD","Valid Passport"],"required":true,"pdf_field":""},{"help":"Tick one valid address proof submitted.","type":"choice","label":"ADDRESS PROOF (ANY ONE)","options":["Aadhar Card*","ID Card Issued by Central/State Govt. to employees","Valid Driving License","Any other Central/State Govt. issued ID","Bank Passbook with stamped photograph (not more than 6 months old)"],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"death claims under individual life policies","attachments":["Original policy document (Not necessary in case of dematerialised policy document)","Death certificate issued by local authority","Claimant's PAN CARD","Claimant's passport size photograph","Cancelled cheque","Medical cause of death certificate (for hospitalization/death due to illness)","Medical records for all the treatments taken in the past (Admission notes, History / Progress sheet, Discharge / Death summary, Test reports, etc.)","First Information Report (FIR), Panchnama / Inquest report, Post-mortem report (PMR), Driving license, Police Final Report, Viscera report (if applicable), Newspaper cutting(s), if any (for accidental death)"],"declarations":["All details filled are true and correct to the best of knowledge and belief.","False or untrue statements or concealment of material facts will forfeit claim rights.","Submission of this form does not guarantee claim processing.","Payout is subject to policy terms and conditions and realization of last renewal premium.","Authorization is given to medical and government institutions to share treatment information with the insurer.","A photocopy of the declaration is valid and effective.","Consent is given to the insurer to share and obtain information with reinsurers, authorities, and other entities for claim processing."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/canara-hsbc-life-insurance/121-individual-death-claim-form"}