{"id":227,"title":"Group Gratuity Claim Form","purpose":"claim","insurer":{"slug":"prudential-hcl-health-insurance","name":"Prudential HCL Health Insurance Limited"},"source_pdf":"https://www.icicilife.com/content/dam/icicipru/download-centre/groupservicingforms/Group_Gratuity_Claim_Form.pdf","sha256":"8b176b0823702c0b6c9f8e09f472fe10c5d651fc0845f19208d5c2826d61a28f","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used to claim gratuity benefits under a group policy, filled by the member, beneficiary, or appointee.","notes":["If leave has been taken on medical grounds, copies of leave applications and medical certificates must be attached.","The claim cheque will be dispatched to the last address recorded by ICICI Life Insurance.","Units to be withdrawn for claim payment will be computed using NAV on the day of receipt of claim intimation or last requirement whichever is later.","Please affix Re. 1/- revenue stamp and sign across the stamp."],"title":"Group Gratuity Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claim Details","fields":[{"help":"","type":"text","label":"Name of the Trust:","options":[],"required":null,"pdf_field":""},{"help":"Select the type of claim","type":"choice","label":"Type of Claim:         Death           Retirement          Resignation","options":["Death","Retirement","Resignation"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"Full name of the member","type":"text","label":"Name of the Member :","options":[],"required":null,"pdf_field":""},{"help":"Full name of the beneficiary","type":"text","label":"Full Name of the Beneficiary :","options":[],"required":null,"pdf_field":""},{"help":"Full name of the appointee if beneficiary is minor","type":"text","label":"Full Name of the Appointee :","options":[],"required":null,"pdf_field":""},{"help":"Member identification number","type":"text","label":"Member ID :","options":[],"required":null,"pdf_field":""},{"help":"Date of birth of the member","type":"date","label":"Date of Birth :","options":[],"required":null,"pdf_field":""},{"help":"Date when member is normally expected to retire","type":"date","label":"Normal Retirement Date :","options":[],"required":null,"pdf_field":""},{"help":"Last salary drawn by the member in rupees","type":"amount","label":"Last Drawn Salary (Rs.) :","options":[],"required":null,"pdf_field":""},{"help":"Total completed years and months of service","type":"number","label":"Completed years & month of service :                 years              months","options":[],"required":null,"pdf_field":""},{"help":"Date and time of death if claim is death type","type":"date","label":"Date and time of death :","options":[],"required":null,"pdf_field":""},{"help":"Exact place of death","type":"text","label":"Place of death (E.g. Address of hospital, City) :","options":[],"required":null,"pdf_field":""},{"help":"Specify exact cause of death or reason for claim","type":"text","label":"Cause of claim :","options":[],"required":null,"pdf_field":""},{"help":"Provide any additional details if claim is due to death","type":"text","label":"Additional Information in case of death claim:","options":[],"required":false,"pdf_field":""},{"help":"Provide From (Date), To (Date), Reasons for leave, Nature of illness (if medical leave)","type":"table","label":"Details of leave taken one year prior to commencement of member's cover:","options":[],"required":false,"pdf_field":""},{"help":"Date when member joined the organization","type":"date","label":"Date of Joining :","options":[],"required":null,"pdf_field":""},{"help":"Last working day of the member","type":"date","label":"Last Working Day :","options":[],"required":null,"pdf_field":""},{"help":"Describe nature of disability if applicable","type":"text","label":"Nature of Disability :","options":[],"required":false,"pdf_field":""},{"help":"Relationship of beneficiary with deceased member","type":"text","label":"Relationship with deceased member :","options":[],"required":null,"pdf_field":""},{"help":"Relationship of appointee with beneficiary","type":"text","label":"Relationship of appointee with beneficiary :","options":[],"required":null,"pdf_field":""},{"help":"Signature of appointee who should be a major if beneficiary is minor","type":"signature","label":"Acceptance & Sign of Appointee :","options":[],"required":null,"pdf_field":""},{"help":"Details of units to be withdrawn for claim payment","type":"text","label":"Details of Withdrawal of units :","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Documents Required for Processing Death Claim","fields":[{"help":"Select cause of claim to know required documents","type":"choice","label":"Cause of claim","options":["Non Accidental Death","Accidental Death / Murder / Suicide"],"required":null,"pdf_field":""},{"help":"Attach documents as per cause of claim: Death certificate, Post Mortem Report, FIR","type":"text","label":"Document required","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Payment Details","fields":[{"help":"Enter claim amount in rupees","type":"amount","label":"Claim amount to be paid (Rs.) :","options":[],"required":null,"pdf_field":""},{"help":"Name of person to whom claim cheque is payable","type":"text","label":"Specify Name of Payee :","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Authorization and Declaration","fields":[{"help":"Affix stamp of the Trust or Company","type":"attachment","label":"Stamp of the Trust / Company :","options":[],"required":null,"pdf_field":""},{"help":"Signature of authorized signatory","type":"signature","label":"Signature of the authorized signatory","options":[],"required":null,"pdf_field":""},{"help":"Name of the authorized signatory","type":"text","label":"Name of the signatory:","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place :","options":[],"required":null,"pdf_field":""}],"filled_by":""}],"deadlines":[],"applies_to":"group gratuity claims including death, retirement, and resignation","attachments":["Copy of Death certificate issued by local authority","Copy of Post Mortem Report","Copy of FIR","Copies of leave applications and medical certificates (if leave taken on medical grounds)"],"declarations":["ICICI Life Insurance shall be discharged of all liabilities upon receipt of claim amount by the payee.","The Trust agrees that ICICI Life Insurance shall be discharged of all liabilities upon payment of the claim moneys."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"customersupport@prudentialhealth.in","label":"Claims Support Email","level":null,"hours":null,"applies_to":"health","source_url":"https://prudentialhealth.in/how-to-claim","quote":"7th Floor, One Unity Center, Senapati Bapat Marg,\nDadar West, Lower Parel, Mumbai – 400013\nGet in Touch\n➔\n1800 268 2000\ncustomersupport@prudentialhealth.in\nInsurance Plans\nHealth Insurance Plans\nPRUHealth Edge\nPRUHealth Signature\nPRUHealth Protect\nPRUHealth Guardian\nTools &","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 268 2000","label":"Claims Support Toll-Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://prudentialhealth.in/how-to-claim","quote":"704 to 1708, 17th Floor, One Unity Center, Senapati Bapat Marg,\nDadar West, Lower Parel, Mumbai – 400013\nGet in Touch\n➔\n1800 268 2000\ncustomersupport@prudentialhealth.in\nInsurance Plans\nHealth Insurance Plans\nPRUHealth Edge\nPRUHealth Signature\nPRUHealth","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/prudential-hcl-health-insurance/227-group-gratuity-claim-form"}