{"id":1242,"title":"INDIVIDUAL DEATH CLAIM FORM","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/Individual_Death_Claim_Form_a5fe9c3b01_66735f64aa.pdf","sha256":"e66ba09d3978f657699433784c7c317425507130e39415eb6f57c8fe683ad6c5","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used by the claimant to request a death claim settlement under an individual life insurance policy.","notes":["Form must be filled by claimant or guardian/appointee if claimant is minor.","Multiple policies can be claimed with one form by listing all policy numbers.","Separate forms needed for multiple claimants.","Sign the form as you normally sign your cheque.","No fee or commission should be paid for claim processing.","Ensure address, phone, and email are current and active.","Fields marked with * are mandatory.","Submit original documents and copies as specified; originals may be required for verification.","Cancelled personalised cheque or latest bank statement/passbook with account number and IFSC must be submitted with NEFT mandate.","NEFT mandate will override previous mandates for all policies with the insurer.","In case of NEFT failure, payout will be on hold until fresh mandate is received.","Report any demand or favour asked by anyone for claim processing immediately to claims@sudlife.in."],"title":"INDIVIDUAL DEATH CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy Details and Life Assured Information","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":""},{"help":"Enter full name of the deceased insured person.","type":"text","label":"Name of Life Assured:","options":[],"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":"Select the place where the death occurred.","type":"choice","label":"Place of Death","options":["Hospital","Clinic","Residence","Office","Other (Please specify)"],"required":true,"pdf_field":""},{"help":"Enter the full name of the father of the life assured.","type":"text","label":"Father's Name:","options":[],"required":false,"pdf_field":""},{"help":"Enter the 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 relevant.","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":false,"pdf_field":""},{"help":"Enter name of family doctor.","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 policy number related to other insurance if any.","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Enter company name of other insurance.","type":"text","label":"Company Name","options":[],"required":false,"pdf_field":""},{"help":"Enter sum assured amount of other insurance.","type":"amount","label":"Sum Assured","options":[],"required":false,"pdf_field":""},{"help":"Select status of other insurance policy.","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":""},{"help":"Describe any illness or habits like smoking, tobacco, drugs with duration and quantity consumed.","type":"text","label":"Nature of Illness and Habit of the insured","options":[],"required":false,"pdf_field":""},{"help":"Enter date when illness was diagnosed.","type":"date","label":"Date of diagnosis of illness","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Claimant","fields":[{"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 of claimant's address.","type":"number","label":"Pincode:","options":[],"required":true,"pdf_field":""},{"help":"Enter claimant's mobile or phone 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 claimant's relation to the deceased.","type":"choice","label":"Relation with the Life Assured:","options":["Spouse","Children","Parents","Others"],"required":true,"pdf_field":""},{"help":"Enter claimant's date of birth.","type":"date","label":"Date of Birth:","options":[],"required":false,"pdf_field":""},{"help":"Provide PAN number 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":"Select claimant's title or role.","type":"choice","label":"Claimant’s Title:","options":["Nominee","Executor","Trustee","Appointee","Employer","Assignee","Beneficiary"],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Claimant NEFT Mandate / Bank Account Details","fields":[{"help":"Select the type of bank account.","type":"choice","label":"Account Type","options":["Savings","Current","NRO","NRE"],"required":true,"pdf_field":""},{"help":"Enter the 11-character IFSC code of the bank branch.","type":"text","label":"IFSC Code (11Characters)","options":[],"required":true,"pdf_field":""},{"help":"Enter the 9-character MICR code if available.","type":"text","label":"MICR Code (9 Characters)","options":[],"required":false,"pdf_field":""},{"help":"Enter the bank account number for claim payout.","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"Enter the name of the bank account holder.","type":"text","label":"Account Holder’s Name","options":[],"required":true,"pdf_field":""},{"help":"Select payout method if applicable.","type":"choice","label":"Mandatory for Pension Plans, Please indicate how you would like to receive the benefits","options":["Entire amount as lumpsum","Entire amount as Annuity","Part as annuity Part as Lumpsump","As Installments"],"required":false,"pdf_field":""},{"help":"Enter bank name and branch details.","type":"text","label":"Bank Name & Branch","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration and Authorisation","fields":[{"help":"Claimant must sign here.","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":""},{"help":"If applicable, third person signs here.","type":"signature","label":"Signature of Third Person","options":[],"required":false,"pdf_field":""},{"help":"Company stamp if applicable.","type":"attachment","label":"Company Stamp","options":[],"required":false,"pdf_field":""},{"help":"Place of third person signing.","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"Date of third person signing.","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Name of person declaring if claimant is minor or thumb impression used.","type":"text","label":"Name of the Declarant","options":[],"required":false,"pdf_field":""},{"help":"Address of declarant.","type":"text","label":"Address","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant and third person"}],"deadlines":[],"applies_to":"death claims under individual life policies","attachments":["Photograph of Claimant","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 (if death due to illness)","Medical records for all 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) (if accidental death)"],"declarations":["All details filled are true and correct to the best of my knowledge and belief.","Submission of this form does not guarantee claim processing.","Payout will be as per policy terms and conditions.","False or untrue statements or concealment of facts will forfeit claim rights.","Payment is subject to realization of last renewal premium.","Authorise medical and government institutions to share treatment information with insurer.","Photocopy of declaration is valid.","Authorise insurer to share and obtain information with reinsurers, authorities, and others for claim processing."],"dropped_labels":1},"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/1242-individual-death-claim-form"}