{"id":1232,"title":"Claim Intimation Form - Group Term","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/GT_Claim_Form_7d8cd65681_fdbcf1c258.pdf","sha256":"e381eed39bd643f830346410d77df695378f67e6dc40794ce0cf5f52d57afa71","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is for intimating a death claim under a group term life insurance policy. It is filled by the master policyholder and the nominee or beneficiary of the insured member.","notes":["All columns must be filled; put NA if not applicable.","Attach original or attested copies of required documents.","Claim form cannot be accepted if any column is left blank."],"title":"Claim Intimation Form - Group Term","submit":{"to":"Star Union Dai-ichi Life Insurance Company Limited, Vashi, Navi Mumbai 400703","how":"By e-mail or by courier","address":"By e-mail: groupclaims@sudlife.in from official email id of the Authorized Signatory; By Courier: Claim Department, Star Union Dai-ichi Life Insurance Company Limited, 11th Floor, Raghuleela Arcade, Sector 30 A, Opposite Vashi Railway Station, Vashi, Navi Mumbai 400703"},"purpose":"claim","sections":[{"title":"Particulars of the Insured Member","fields":[{"help":"","type":"text","label":"Name of the Company","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Master Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Full name of the insured member","type":"text","label":"Full name","options":[],"required":true,"pdf_field":""},{"help":"Address of the insured member","type":"text","label":"Residential Address","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of the insured member","type":"date","label":"Date of birth (as per records)","options":[],"required":true,"pdf_field":""},{"help":"Date when the insured member joined the policy","type":"date","label":"Date of Joining the Policy","options":[],"required":true,"pdf_field":""},{"help":"Certificate of Insurance number","type":"text","label":"COi No.","options":[],"required":true,"pdf_field":""},{"help":"Select the type of death","type":"choice","label":"Type of Death","options":["Natural","Accidental"],"required":true,"pdf_field":""},{"help":"Date when the insured member died","type":"date","label":"Date of Death","options":[],"required":true,"pdf_field":""},{"help":"Brief cause of death","type":"text","label":"Cause of Death","options":[],"required":true,"pdf_field":""},{"help":"Location where death occurred","type":"text","label":"Place of Death","options":[],"required":true,"pdf_field":""},{"help":"Name of the nominee","type":"text","label":"Nominee of the Insured Member","options":[],"required":true,"pdf_field":""},{"help":"Contact number of the nominee","type":"phone","label":"Telephone No./ Mobile No. of the Nominee","options":[],"required":true,"pdf_field":""},{"help":"Bank account number of the nominee","type":"text","label":"Nominee Saving account no","options":[],"required":true,"pdf_field":""},{"help":"Name of the nominee's bank","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of the nominee's bank branch","type":"text","label":"IFSC code","options":[],"required":true,"pdf_field":""}],"filled_by":"master policyholder"},{"title":"To be Filled by Master Policy Holder","fields":[{"help":"Date when premium was debited","type":"date","label":"Premium Debit Date","options":[],"required":true,"pdf_field":""},{"help":"Amount of premium paid","type":"amount","label":"Premium Amount","options":[],"required":true,"pdf_field":""},{"help":"Basic sum assured under the policy","type":"amount","label":"Basic Sum Assured","options":[],"required":true,"pdf_field":""},{"help":"Branch of the insurer","type":"text","label":"Branch Name","options":[],"required":true,"pdf_field":""},{"help":"Code of the branch","type":"text","label":"Branch Code","options":[],"required":true,"pdf_field":""}],"filled_by":"master policyholder"},{"title":"Declaration and Signatures","fields":[{"help":"Sign and print name of beneficiary or nominee","type":"signature","label":"Name and Signature of Beneficiary/ies","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Contact number of beneficiary","type":"phone","label":"Phone no.","options":[],"required":true,"pdf_field":""},{"help":"Bank branch manager's signature and seal","type":"signature","label":"Signature of Bank Branch Manager with Bank Seal","options":[],"required":true,"pdf_field":""},{"help":"Contact number of bank branch manager","type":"phone","label":"Contact No./ Mobile No. of the Bank Branch Manager","options":[],"required":true,"pdf_field":""}],"filled_by":"beneficiary/nominee and bank branch manager"},{"title":"Advance Discharge Voucher","fields":[{"help":"Policy number","type":"text","label":"Policy no.","options":[],"required":true,"pdf_field":""},{"help":"Name of the beneficiary","type":"text","label":"Name of the Beneficiary","options":[],"required":true,"pdf_field":""},{"help":"Date of death of the insured member","type":"date","label":"Date of Death","options":[],"required":true,"pdf_field":""},{"help":"Signature of a witness","type":"signature","label":"Signature of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Bank branch manager's signature and seal","type":"signature","label":"Signature of Bank Branch Manager with Bank Seal","options":[],"required":true,"pdf_field":""}],"filled_by":"beneficiary/nominee and bank branch manager"}],"deadlines":[],"applies_to":"death claims under group term life insurance policies","attachments":["Copy of Bank Pass Book of the Nominee","Death Certificate of the Member duly attested by Group Administrator","Copy of Bank Passbook of the Life Assured showing premium debit entry, duly attested","Original COi","Copy of Bank Passbook of the Nominee/ Beneficiary or Cancelled Cheque (with pre-printed name of the Nominee)","For accidental death: First Information Report, Spot Panchanama, Post Mortem Report"],"declarations":["The statements made in the form are true and correct to the best of the knowledge of the declarant.","The amount mentioned is the full and final settlement of claims and demands under the master policy for the life assured."],"dropped_labels":8},"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/1232-claim-intimation-form-group-term"}