{"id":232,"title":"Group Term / Employee Deposit Linked Insurance - Claim Intimation 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_Claim_Form_Employer_Employee_Scheme_(Term_&_EDLI).pdf","sha256":"9ffaf9e9a95e4707797c574bee123c5a4f6beadfc4e91a612c346cffc3bd05e6","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is used to intimate a claim under the Group Term or Employee Deposit Linked Insurance policies. It is filled by the employer or authorized company representative on behalf of the insured member or nominee.","notes":["Mandatory details are marked with * and must be filled.","Attach original or certified copies of required documents as listed.","Use official email ID of authorized signatory when submitting by email.","Claim cheque will be sent to the last address recorded by the insurer.","The company may request additional documents as needed.","Turnaround time for claim processing starts only after receipt of all mandatory documents.","Death Benefit payout options include lump sum or income installments over 2 to 5 years.","Monthly income payout percentages and total benefit percentages are provided for income option.","Revenue stamp of Re. 1/- must be affixed and signed across by the company."],"title":"Group Term / Employee Deposit Linked Insurance - Claim Intimation Form","submit":{"to":"Group Service Desk, ICICI Life Insurance Limited","how":"By email or courier","address":"Email: grouplife@icicilife.com; Postal: Unit No 901A, 901B, Prism Tower, Mindspace, Link Road, Goregaon (West), Mumbai - 400 104"},"purpose":"claim","sections":[{"title":"Claim Details","fields":[{"help":"Enter the date of filling the form in DD MM YYYY format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Select the type of policy under which claim is made","type":"choice","label":"Type of Policy*","options":["Group Term","Employee Deposit Linked Insurance"],"required":true,"pdf_field":""},{"help":"Enter the policy number","type":"text","label":"Policy Number*","options":[],"required":true,"pdf_field":""},{"help":"Select the type of claim being intimated","type":"choice","label":"Type of Claim*","options":["Death","Critical Illness","Accidental Total & Permanent Disability Benefit Rider","Accidental Death Benefit Rider","Terminal Illness"],"required":true,"pdf_field":""},{"help":"Enter the full name of the insured member","type":"text","label":"Name of the Member*","options":[],"required":true,"pdf_field":""},{"help":"Enter the member identification number","type":"text","label":"Member ID*","options":[],"required":true,"pdf_field":""},{"help":"Enter member's date of birth","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Enter date and time of death if applicable","type":"date","label":"Date & time of death/*","options":[],"required":null,"pdf_field":""},{"help":"Enter date of diagnosis of Critical Illness or date of disability","type":"date","label":"Date of diagnosis of CI / Date of Disability","options":[],"required":null,"pdf_field":""},{"help":"Enter place or address where death occurred","type":"text","label":"Place of death (E.g. Address of hospital)","options":[],"required":null,"pdf_field":""},{"help":"Provide exact cause or medical condition related to claim","type":"text","label":"Cause of Death/Claim* (Please specify exact cause of death or exact medical condition of CI or exact reason for disability)","options":[],"required":true,"pdf_field":""},{"help":"Enter last working date if applicable","type":"date","label":"Last working date (If applicable)","options":[],"required":null,"pdf_field":""},{"help":"Enter sum assured amount","type":"amount","label":"Sum Assured*","options":[],"required":true,"pdf_field":""},{"help":"Enter rider sum assured if applicable","type":"amount","label":"Rider Sum Assured (If applicable)","options":[],"required":null,"pdf_field":""},{"help":"Enter annual cost to company or monthly income if sum assured exceeds 10 lakhs","type":"amount","label":"Annual CTC/ Monthly Income (If Sum Assured is above 10 lakhs)","options":[],"required":null,"pdf_field":""},{"help":"Enter start date of leave taken before cover start","type":"date","label":"Details of leave taken one year prior to commencement of member's cover: (If applicable) From (Date)","options":[],"required":null,"pdf_field":""},{"help":"Enter end date of leave taken before cover start","type":"date","label":"To (Date)","options":[],"required":null,"pdf_field":""},{"help":"Specify reason for leave","type":"text","label":"Reasons for Leave","options":[],"required":null,"pdf_field":""},{"help":"Specify illness nature if leave was medical","type":"text","label":"Nature of Illness (in case of leave on medical grounds)","options":[],"required":null,"pdf_field":""},{"help":"Enter name of nominee or appointee for claim payout cheque","type":"text","label":"Nominee/Appointee Name","options":[],"required":null,"pdf_field":""},{"help":"Enter relationship of nominee/appointee to member","type":"text","label":"Relationship","options":[],"required":null,"pdf_field":""},{"help":"Enter percentage share of claim amount for nominee","type":"number","label":"Share % of Claim Amount","options":[],"required":null,"pdf_field":""},{"help":"Enter nominee's date of birth","type":"date","label":"Nominee Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Enter contact details of nominee","type":"text","label":"Nominee Contact Details","options":[],"required":null,"pdf_field":""}],"filled_by":"employer or authorized company representative"},{"title":"Payment Details and Declaration","fields":[{"help":"Enter the amount to be paid","type":"amount","label":"Term Amount to be paid (In `) :","options":[],"required":null,"pdf_field":""},{"help":"Enter name of the payee for claim payment","type":"text","label":"Specify Name of Payee :","options":[],"required":null,"pdf_field":""},{"help":"Affix company stamp across the revenue stamp","type":"signature","label":"Stamp of the Company","options":[],"required":null,"pdf_field":""},{"help":"Authorized signatory must sign here","type":"signature","label":"Signature of the authorized signatory","options":[],"required":null,"pdf_field":""},{"help":"Enter name of the authorized signatory","type":"text","label":"Name of the signatory","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""}],"filled_by":"employer or authorized company representative"}],"deadlines":[],"applies_to":"Group Term / Employee Deposit Linked Insurance claims including Death, Critical Illness, Accidental Total & Permanent Disability Benefit Rider, Accidental Death Benefit Rider, Terminal Illness","attachments":["Copies of leave applications and medical certificates if leave was taken on medical grounds","Claim form","Two Treating doctor's certificate for Terminal Illness claims","Member KYC","Member’s bank account details (cancelled cheque copy)","First and all consultation papers with investigation reports, discharge summary, Indoor case papers, follow up papers","Income Proof - Salary slip of 6 months (additional requirements may be raised)","Current and previous medical records for last 5 years, if any","Other Insurance policy documents (if required) - Life/health/Mediclaim with past claim settlement letters","Copy of Death Certificate for Death Claims","Beneficiary bank account details (cancelled cheque/passbook copy)","Last 2 Months Paid Salary Slip of the member (If sum assured is above 10 lakhs)","Sick Leave records of one year prior to scheme joining date (if applicable)","RTPCR report/death summary if cause of death is COVID-19","Certificate of Illness/Disability from Medical Practitioner for Accidental Total & Permanent Disability Rider","Treating doctor’s certificate confirming disability lasting more than 180 days","First Information Report (FIR)/Police Final report for Accidental Death Benefit Rider","Post-mortem report (PMR) for Accidental Death Benefit Rider","Hospital treatment papers, Panchnama/Inquest report if required"],"declarations":["ICICI Life Insurance Limited shall be discharged of all liabilities upon payment of claim moneys.","The insured member/nominee/beneficiary submitting the claim is the same person registered under the Group Master Policy.","Payout under the policy shall be strictly in accordance with policy terms and conditions.","The particulars given in this form are true, correct and complete and the signatory takes full responsibility for their correctness.","The company is not responsible for delays or non-receipt of payment due to incorrect or incomplete information.","Consent is given to ICICI Life Insurance Limited to obtain additional documents or information required to settle the claim.","The signatory agrees to indemnify ICICI Life against liabilities from claims by others based on possession of the policy document."],"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/232-group-term-employee-deposit-linked-insurance-claim-intimation-form"}