{"id":228,"title":"PRADHAN MANTRI JEEVAN JYOTI BIMA YOJANA (PMJJBY) CLAIM-CUM-DISCHARGE 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/Claimforms/PMJJBY-English.pdf","sha256":"4a71b1108db6231f65e4122d2fad06031c6cb943bf5b0968f9acf9461f333ff7","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is for claiming the insurance amount under the PMJJBY scheme after the death of the insured member. It is filled by the nominee, or if the nominee is a minor, by the appointee, or if there is no nominee or the nominee has predeceased, by the claimant legal heirs.","notes":["The appointee is the person named by the deceased member in his PMJJBY enrolment form where the nominee is a minor","A claimant where there is no nomination or the nominee has predeceased the insured member shall be one who is a legal heir and submits a succession certificate or legal heir certificate issued by a competent court or authority","Accident means a sudden, unforeseen and involuntary event caused by external, violent and visible means","No claim shall be payable in case of death occurring within 30 days from the date of joining/rejoining the policy, except in case of death due to accident","Documents acceptable as proof of death and accident are listed in the form","Aadhaar and PAN information is desirable but not mandatory","KYC documents acceptable include Aadhaar card, electoral photo identity card, MGNREGA card, driving license, PAN card or passport","Use original documents for proof of death and identity","Attach first two pages of passbook or bank/post office account statement or cancelled cheque for bank details"],"title":"PRADHAN MANTRI JEEVAN JYOTI BIMA YOJANA (PMJJBY) CLAIM-CUM-DISCHARGE FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Part 1. Details of the deceased member enrolled under PMJJBY","fields":[{"help":"","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of Village /Town / City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of District","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of State","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"PIN Code","options":[],"required":true,"pdf_field":""},{"help":"Account number where the insured member held the account","type":"text","label":"Bank / Post office account number:","options":[],"required":true,"pdf_field":""},{"help":"Date when the insured member died","type":"date","label":"Date of death:","options":[],"required":true,"pdf_field":""}],"filled_by":"nominee or appointee or claimant"},{"title":"Part 2. Details of the nominee (or appointee or claimant)","fields":[{"help":"","type":"text","label":"Name of the nominee:","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Age of nominee:","options":[],"required":true,"pdf_field":""},{"help":"Fill only if nominee is minor","type":"text","label":"In case the nominee is a minor, name of the appointee:","options":[],"required":false,"pdf_field":""},{"help":"Fill only if no nominee or nominee predeceased","type":"text","label":"In case of no nomination or nominee pre-deceasing the insured member, name of the claimant:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship of the nominee/claimant with the deceased:","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact mobile number:","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Contact email address:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Contact address:","options":[],"required":true,"pdf_field":""},{"help":"Bank account for claim payment","type":"text","label":"Details of the nominee/appointee/claimant (as the case may be): Particulars of bank account into which the claim amount is to be remitted: Account number:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of bank:","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of the bank branch","type":"text","label":"Branch IFS Code:","options":[],"required":true,"pdf_field":""}],"filled_by":"nominee or appointee or claimant"},{"title":"Declaration and signature","fields":[{"help":"Date of signing the form","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of nominee/appointee/claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"nominee or appointee or claimant"},{"title":"Part 3: Details in respect of the deceased insured member (to be filled by bank / post office)","fields":[{"help":"","type":"text","label":"Bank / Post office account number (as per bank’s CBS/ post office records):","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank / Post office name:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch name:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch IFS Code:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of father/husband of the deceased member:","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date of birth (as per KYC document):","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the insurer:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the nominee:","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date of debit of premium from the bank / post office account:","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date of remitting the premium into insurer’s account:","options":[],"required":true,"pdf_field":""},{"help":"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":""},{"help":"Signature and seal by bank/post office official","type":"signature","label":"Signature and seal of the authorised official of the bank/ post office","options":[],"required":true,"pdf_field":""}],"filled_by":"bank / post office"},{"title":"Advance receipt for discharge of claim","fields":[{"help":"Name of insurer paying the claim","type":"text","label":"Name of the insurer","options":[],"required":true,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Signature of the witness","options":[],"required":true,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of witness:","options":[],"required":true,"pdf_field":""},{"help":"Signature of claimant","type":"signature","label":"Signature of nominee/appointee/claimant","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Signature of bank/post office official","type":"signature","label":"Countersignature of authorised official of the bank / post office","options":[],"required":true,"pdf_field":""},{"help":"Date of countersignature","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of bank / post office:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch:","options":[],"required":true,"pdf_field":""},{"help":"Stamp of bank/post office","type":"attachment","label":"Office stamp:","options":[],"required":true,"pdf_field":""}],"filled_by":"nominee/appointee/claimant and bank/post office official"}],"deadlines":["To be submitted preferably within 30 days of death of insured member"],"applies_to":"death claims under PMJJBY","attachments":["Proof of death of the insured member (Proof of death due to accident if death is within 30 days of joining / rejoining the policy)","Aadhaar number and PAN number of deceased member and nominee / appointee / claimant (Optional)","KYC document in respect of the nominee / appointee / claimant","First two pages of passbook, or bank / post office account statement showing account details, or cancelled cheque of the account of nominee / appointee / claimant","Proof of death of nominee, in case the nominee has predeceased the insured member","Proof of claimant being the legal heir, in case claimant is other than nominee/appointee","Advance receipt for discharge of claim, duly filled in and signed"],"declarations":["I hereby declare that details submitted above are true to the best of my knowledge","The documents attached in support of this claim are genuine","I have not claimed the amount payable under PMJJBY in respect of the deceased member named above earlier or in respect of any other account of the deceased with any bank or post office","It is certified by the bank/post office official that the information in Part 3 is true as per enrolment data and bank/post office records","By signing the advance receipt, the claimant accepts the sum in full and final settlement and discharge of the claim"],"dropped_labels":10},"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/228-pradhan-mantri-jeevan-jyoti-bima-yojana-pmjjby-claim-cum-discharge-form"}