{"id":222,"title":"INDIVIDUAL DEATH CLAIM FORM","purpose":"claim","insurer":{"slug":"hdfc-ergo-general-insurance","name":"HDFC ERGO General Insurance Company Limited"},"source_pdf":"https://www.hdfclife.com/content/dam/hdfclifeinsurancecompany/customer-services/form-and-download/other-documents/individual-death-claim-form-proposed-standard.pdf","sha256":"e22dcdddec09bb04739faa9dcc6478be8d36ba5a3d8800c35b2e1ed2a34822a3","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the claimant to file a death claim under an individual life insurance policy. The claimant or their guardian/appointee fills it.","notes":["Form must be filled by claimant or guardian/appointee if claimant is minor","Claims under multiple policies can be registered with a single form","Separate forms needed for multiple claimants","Sign the form as you normally sign your cheque","No fee or commission should be paid to anyone for claim processing","Ensure address, phone, and email are current and active","Asterisk (*) indicates mandatory fields","Submit original documents for verification and copies with the form","Cancelled personalised cheque or bank passbook copy must be submitted with NEFT mandate","NEFT mandate overrides previous mandates for all policies with HDFC Life","In case of NEFT failure, payout will be on hold until fresh mandate is received","For NRE account refunds, submit bank statement or confirmation letter as evidence","Use block letters where applicable","Beware of fraudulent calls and offers; report suspicious activity to company email"],"title":"INDIVIDUAL DEATH CLAIM FORM","submit":{"to":"Claims department, HDFC Life Insurance Company Limited","how":"post or in person","address":"13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011"},"purpose":"claim","sections":[{"title":"Details of Life Assured (LA) - 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":""},{"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 full name of the deceased life assured.","type":"text","label":"Name of Life Assured:","options":[],"required":true,"pdf_field":""},{"help":"Enter 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":false,"pdf_field":""},{"help":"Enter name of the company where the life assured was employed, 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 details of last employer 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:","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 doctor who treated the life assured.","type":"text","label":"Last treated/attended Doctor Name:","options":[],"required":false,"pdf_field":""},{"help":"Enter registration number of last treated doctor.","type":"text","label":"Registration no.:","options":[],"required":false,"pdf_field":""},{"help":"Enter contact number of last treated doctor.","type":"phone","label":"Contact no.:","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Claimant","fields":[{"help":"Provide PAN details or Form 97/Form 60 if PAN not available.","type":"text","label":"Claimant's PAN details: Or Form 97 (corresponding 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 relationship to the policy.","type":"choice","label":"Claimant’s Title:","options":["Nominee","Executor","Trustee","Appointee","Employer","Assignee","Beneficiary"],"required":true,"pdf_field":""},{"help":"Enter full name of the claimant.","type":"text","label":"Claimant Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal 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 life assured; specify if 'Others'.","type":"choice","label":"Relation with the Life Assured:","options":["Spouse","Children","Parents","Others (Specify)"],"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":"Other Insurance and Health Details","fields":[{"help":"Provide details of other insurance policies including Policy No., Company Name, Sum Assured, Status.","type":"table","label":"Other Insurance details: (Life/Mediclaim/Health)","options":[],"required":false,"pdf_field":""},{"help":"Describe any illnesses and habits such as Hypertension, Diabetes, Heart disease, etc.","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":""},{"help":"Provide details if applicable.","type":"text","label":"Smoking / Tobacco / Drugs - If yes, Duration of Consumption & Quantity Consumed:","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Claimant NEFT Mandate / Bank Account Details","fields":[{"help":"Select type of bank account.","type":"choice","label":"Account Type:","options":["Savings","Current","NRO","NRE"],"required":true,"pdf_field":""},{"help":"Enter bank account number for claim payout.","type":"text","label":"Bank Account No.:","options":[],"required":true,"pdf_field":""},{"help":"Enter name of the bank account holder.","type":"text","label":"Account Holder Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code of the bank branch (11 characters).","type":"text","label":"IFSC:","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR code of the bank branch (9 characters).","type":"text","label":"MICR:","options":[],"required":false,"pdf_field":""},{"help":"Enter full bank name and branch.","type":"text","label":"Bank Name & Branch:","options":[],"required":true,"pdf_field":""},{"help":"Select preferred mode of benefit payment 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 Lumpsum","As Installments"],"required":false,"pdf_field":""},{"help":"Sign here to authorize bank details and claim.","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Enter place where form is signed.","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 to be made by a Third Person","fields":[{"help":"Enter full name of the person declaring on behalf of claimant.","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":""},{"help":"Declarant must sign here.","type":"signature","label":"Signature of Third Person","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":"third person"},{"title":"Consent Form","fields":[{"help":"Enter policy number(s) related to the claim.","type":"text","label":"Policy Number(s):","options":[],"required":true,"pdf_field":""},{"help":"Enter claimant's full name.","type":"text","label":"Name of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Sign here to give consent for obtaining records.","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"death claims under individual life policies","attachments":["Death certificate issued by local authority","Claimant's passport size photograph","Personalised Cancelled Cheque or Bank Passbook (with Printed A/c no, IFSC & Name account holder)","Claimant's Valid Identity Proof","Claimant's Valid Address Proof","Claimant's PAN CARD/Form 97 (corresponding Form 60) (if PAN Card not available)","Original policy document (Not necessary in case of dematerialised policy document)","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) (if accidental death)","Panchanama / Inquest report (if accidental death)","Post-mortem report (PMR) (if accidental death)","Driving license (if accidental death)","Police Final Report (if accidental death)","Viscera report (if applicable)","Newspaper cutting(s), if any","Employer’s certificate (Form) for Life Assured, if employed (not required for pension/annuity plans)"],"declarations":["All details filled are true and correct to the best of my knowledge","False or untrue statements or concealment will forfeit claim rights","Submission of form does not guarantee claim processing","Payout is subject to policy terms and last premium payment","Authorise medical and government institutions to share treatment information with HDFC Life","Photocopy of this declaration is valid","Authorise HDFC Life to share and obtain information with reinsurers, insurers, authorities, and others","Consent given to HDFC Life to obtain employment, medical, death, and other records related to the deceased"],"dropped_labels":3},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"phone","value":"022 6158 2020","label":"Claim/Policy related queries","level":null,"hours":null,"applies_to":"all","source_url":"https://www.hdfcergo.com/disclaimer-and-privacy-policy/dpp","quote":"usiness District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at\n022 6158 2020\nor Visit Help Section on\nwww.hdfcergo.com\nfor policy copy/tax certificate/make changes/register & track claim. IRDAI Re","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"08041763550","label":"Bike Insurance Claim Contact","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.hdfcergo.com/claim/register-bike-insurance-claim/cashless-claims","quote":"Buy\nRenewal\nClaim\nSupport\nOthers\nCall to Buy -\n08041763550\nHelp\nRegister claim online\nView plans now. Buy when you are ready.\nTrack Claim\nClaim already registered?\nClick Here to","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/hdfc-ergo-general-insurance/222-individual-death-claim-form"}