{"id":1231,"title":"ADVANCE DISCHARGE VOUCHER - DEATH CLAIM PROCEEDS","purpose":"claim","insurer":{"slug":"star-union-dai-ichi-life-insurance","name":"Star Union Dai-Ichi Life Insurance Company Limited"},"source_pdf":"https://dxwkpt4djlxwl.cloudfront.net/Advance_Discharge_Voucher_Form_Multilingual_6c4f937ebe_51715f69d6.pdf","sha256":"b48106633018b6335dc2340b2609078df86302e908ba5c141fc1a6e8a3cbae65","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is used by the nominee to acknowledge receipt of the death claim proceeds under a life insurance policy from Star Union Dai-ichi Life Insurance Company Ltd.","notes":["Affix a Re 1/- revenue stamp and sign across the stamp.","The witness must be one of the specified eligible persons and not related to the deceased.","Third party declaration is required if the policyholder has signed in vernacular, affixed thumb impression, or not filled the application."],"title":"ADVANCE DISCHARGE VOUCHER - DEATH CLAIM PROCEEDS","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Policyholder:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Life Assured:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"FlaVPlot No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Building Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Road:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Landmark:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City/District:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Include country/area code if applicable","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Declaration and Payment Details","fields":[{"help":"Enter full name of the nominee","type":"text","label":"I, Mr/Ms/Mrs./Dr.","options":[],"required":true,"pdf_field":""},{"help":"Enter amount received in figures","type":"amount","label":"hereby acknowledge receipt of","options":[],"required":true,"pdf_field":""},{"help":"Enter amount received in words","type":"text","label":"(in words)","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of the deceased life assured","type":"text","label":"towards the above mentioned policy on the life of Mr/Ms/Mrs./Dr.","options":[],"required":true,"pdf_field":""},{"help":"Enter sum assured amount","type":"amount","label":"Sum Assured under the policy:","options":[],"required":true,"pdf_field":""},{"help":"Enter mortality charges deducted","type":"amount","label":"Less: Mortality Charges:","options":[],"required":true,"pdf_field":""},{"help":"Enter fund value already paid if applicable","type":"amount","label":"Less: Fund Value Already Paid:","options":[],"required":false,"pdf_field":""},{"help":"Enter net claim amount payable","type":"amount","label":"Net Claim Amount payable","options":[],"required":true,"pdf_field":""},{"help":"Enter claimant or nominee full name","type":"text","label":"Claimant/Nominee: Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of witness","type":"text","label":"Witness: Name:","options":[],"required":true,"pdf_field":""}],"filled_by":"Nominee"},{"title":"Declaration by Third Party","fields":[{"help":"Enter full name of declarant","type":"text","label":"I, Mr./Ms./Dr.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"do declare that I have explained the contents of this form to the policyholder in his/her language and have truthfully recorded the answers provided by him/her. I further declare that the policyholder has affixed his signature/thumb impression in my presence.","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Declarant:","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""}],"filled_by":"Third Party"}],"deadlines":[],"applies_to":"death claim proceeds under life insurance policies","attachments":["Revenue stamp of Re 1/- affixed and signed across"],"declarations":["The nominee acknowledges receipt of the claim amount as full and final settlement.","The witness must be an eligible person not related to the deceased.","If the policyholder has signed in vernacular, affixed thumb impression, or not filled the application, a third party must declare having explained the form and witnessed the signature/thumb impression."],"dropped_labels":10},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"customercare@sudlife.in","label":"Customer Care Email","level":null,"hours":null,"applies_to":"all","source_url":"https://irdai.gov.in/documents/37343/563751/GEBP+Master+Pol+doc_2020-21.pdf/a5b92dec-159b-de50-83f9-52e6f268a1fc?version=1.1&t=1667460674786&download=true","quote":"ly check the Master Policy details and the terms & conditions carefully. If you have any queries, please write to us at customercare@sudlife.in.\nIn case You are not satisfied with the terms and conditions of the Master policy, then you may return the Master polic","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18002668833","label":"Toll Free No","level":null,"hours":null,"applies_to":"all","source_url":"https://irdai.gov.in/documents/37343/563751/GEBP+Master+Pol+doc_2020-21.pdf/a5b92dec-159b-de50-83f9-52e6f268a1fc?version=1.1&t=1667460674786&download=true","quote":"or any assistance relating to your Master Policy or claim related query, you may get in touch with us via Toll Free No: 18002668833 or email Us at: customercare@sudlife.in\nThanking you once again for your patronage and looking forward to your continue","fetched_at":"2026-10-20"}],"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/star-union-dai-ichi-life-insurance/1231-advance-discharge-voucher-death-claim-proceeds"}