{"id":229,"title":"Claim Statement Form -  Affinity / Employer-Employee Group","purpose":"claim","insurer":{"slug":"prudential-hcl-health-insurance","name":"Prudential HCL Health Insurance Limited"},"source_pdf":"https://www.icicilife.com/content/dam/icicipru/claims-documents/Claimant_Statement_Form-Non-Loan_Linked_Group.pdf","sha256":"10626936e89a957d435de54bb7442720cc896ee2c52da848d5de9e886602b29c","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is used by the claimant or nominee to submit a claim under an Affinity or Employer-Employee Group insurance policy.","notes":["This form should be used only for Affinity / Employer-Employee Group policies.","As per regulatory requirement, Insurers are required to pay all payout due to policyholders/ nominee/ assignee by directly crediting the money into their bank account."],"title":"Claim Statement Form -  Affinity / Employer-Employee Group","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Information of Claimant / Nominee","fields":[{"help":"","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mob No:","options":[],"required":null,"pdf_field":""},{"help":"Specify your relationship to the insured member","type":"text","label":"Relationship with Member:","options":[],"required":null,"pdf_field":""},{"help":"Full name of the claimant or nominee","type":"text","label":"Claimant / Nominee Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"Bank where claimant holds account","type":"text","label":"Bank Name:","options":[],"required":null,"pdf_field":""},{"help":"Branch details of the bank","type":"text","label":"Branch Name & Address:","options":[],"required":null,"pdf_field":""},{"help":"Account number for payout","type":"text","label":"Bank Account Number:","options":[],"required":null,"pdf_field":""},{"help":"Indian Financial System Code of the bank branch","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"Magnetic Ink Character Recognition code of the bank branch","type":"text","label":"MICR Code","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or nominee"},{"title":"Authorization and Declaration","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign and print your name","type":"signature","label":"Name & Signature of the Nominee / Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or nominee"},{"title":"Declaration by the Master Policyholder","fields":[{"help":"Enter sum assured amount","type":"amount","label":"Sum Assured for which the member of the Group Insurance Policy was insured INR:","options":[],"required":null,"pdf_field":""},{"help":"Master policyholder to sign and print name","type":"signature","label":"Name & Signature of the Master Policy Holder","options":[],"required":true,"pdf_field":""},{"help":"Date of signing (DD/MM/YYYY)","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""}],"filled_by":"master policyholder"},{"title":"Policy Details","fields":[{"help":"ID of the insured member","type":"text","label":"Member ID:","options":[],"required":null,"pdf_field":""},{"help":"Group master policy number","type":"text","label":"Master Policy number(s):","options":[],"required":null,"pdf_field":""},{"help":"Name of the insured member","type":"text","label":"Member Name:","options":[],"required":null,"pdf_field":""},{"help":"Date of death or event (DD/MM/YYYY)","type":"date","label":"Date of Death/ Event:","options":[],"required":null,"pdf_field":""},{"help":"Select cause of death or specify if Others","type":"choice","label":"Cause of Death:","options":["Accidental","Non-Accidental","Suicide","Others"],"required":null,"pdf_field":""},{"help":"If 'Others' selected, specify cause","type":"text","label":"Please specify","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or nominee"}],"deadlines":[],"applies_to":"Affinity / Employer-Employee Group policies","attachments":["Certificate of Insurance (COI)","Copy of death certificate issued by local authority","Claimants current address proof","Claimants photo identity proof","Claimants Cancelled cheque/ Copy of bank passbook","Copy of FIR (for Accidental Death)","Panchnama (for Accidental Death)","Inquest report (for Accidental Death)","Postmortem report (for Accidental Death)","Driving Licence (for Accidental Death)","Definition Fulfillment Document (All Medical reports, case histories, investigation, reports, treatment papers, discharge summaries, precise diagnosis of the treatment for which a claim is made) (for Rider/Living Benefits)"],"declarations":["I understand that any payout under the policy shall be strictly in accordance with the policy terms and conditions.","I hereby declare that the particulars given in this form are true, correct and complete in all aspects and I take full responsibility of the genuineness and correctness of the details filled herein.","If any transaction is delayed or not effected at all or for non-receipt of any payment on account of wrong/ incorrect/ incomplete information given by me in this form, I shall not hold the company responsible in any manner whatsoever.","I hereby give my consent to ICICI Prudential Life Insurance Co Ltd and its representatives to obtain additional documents and/or information as is required to settle this claim and I request the relevant authorities to release the sought information to ICICI Prudential Life Insurance Co Ltd and its representatives.","I hereby agree to indemnify ICICI Prudential against all liabilities that ICICI Prudential may incur on account of any claim being made by any other person on the basis of possession of the Policy document, Certificate of insurance or otherwise.","The Insured member/ Nominee/ Beneficiary who had submitted the Claim Statement form is the same person who has been registered by the Master Policy holder as the Insured Member/ Nominee/ Beneficiary under the Group Master Policy."],"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/229-claim-statement-form-affinity-employer-employee-group"}