{"id":233,"title":"INTIMATION OF DEATH 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/groupannuityrelatedforms/Death_Claim_Intimation.pdf","sha256":"63c7ce3dc8e6fa38c0e2fa6a23a9ee40dbca02ac398cedb0b96ef997eedc9876","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by the nominee or beneficiary to notify ICICI Life Insurance Limited of the death of the annuitant under an annuity policy and to initiate the death claim process.","notes":["Use original documents where specified.","Turnaround time for claim processing starts only after receipt of all mandatory documents.","The company may call for additional documents or requirements.","For assistance, contact myannuity@icicilife.com or call 1860 266 1999 (option 1 for Group Annuity).","Do not prefix '+' or '91' or '00' before the phone number when calling.","Call center timings: 10.00 A.M. to 7.00 P.M. Monday to Saturday (except national holidays).","Insurance is the subject matter of solicitation."],"title":"INTIMATION OF DEATH FORM","submit":{"to":"Group Annuity Service Desk, ICICI Life Insurance Limited, Unit No. 901A, Prism Towers, Mindspace, Link Road, Goregaon (West), Mumbai - 400 104.","how":"post","address":"Unit No. 901A, Prism Tower, Mindspace, Link Road, Goregaon (West), Mumbai - 400 104."},"purpose":"claim","sections":[{"title":"Claim Details and Annuitant Information","fields":[{"help":"Enter the annuity policy number(s) for which the death claim is being made","type":"text","label":"Annuity Policy Number(s) :","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the annuitant","type":"text","label":"Name of Annuitant","options":[],"required":null,"pdf_field":""},{"help":"Enter the name(s) of the beneficiary or beneficiaries","type":"text","label":"Name of beneficiary / beneficiaries","options":[],"required":null,"pdf_field":""},{"help":"Specify your relationship with the annuitant","type":"text","label":"Relationship with the Annuitant :","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of death in DD/MM/YYYY format","type":"date","label":"Date of death","options":[],"required":null,"pdf_field":""},{"help":"Enter the place where the death occurred","type":"text","label":"Place of death","options":[],"required":null,"pdf_field":""},{"help":"Specify the cause of death","type":"text","label":"Cause of death","options":[],"required":null,"pdf_field":""},{"help":"Enter the age in years","type":"number","label":"Age of the annuitant at the time of death","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the joint life annuitant if applicable","type":"text","label":"Name of joint life (if applicable)","options":[],"required":false,"pdf_field":""},{"help":"Sign the form here","type":"signature","label":"Signature of beneficiary/beneficiaries","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of signing in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter the place where the form is signed","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full postal address","type":"text","label":"Address of beneficiary / beneficiaries","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid email address","type":"email","label":"E-Mail ID:","options":[],"required":false,"pdf_field":""},{"help":"Enter home phone number","type":"phone","label":"Contact Details: Home No.","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Enter the MICR code of the bank branch","type":"text","label":"MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Enter the name of the bank","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank branch name","type":"text","label":"Branch Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank account number for electronic fund transfer","type":"text","label":"Account No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the IFSC code of the bank branch","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"Enter the full address of the bank branch","type":"text","label":"Branch Address","options":[],"required":false,"pdf_field":""}],"filled_by":"nominee/beneficiary"},{"title":"Nominee Declaration","fields":[{"help":"Please read and agree to all declarations","type":"checkbox","label":"Nominee Declaration","options":["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 Life Insurance Limited 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 Life Insurance Limited and its representatives.","I hereby agree to indemnify ICICI Life against all liabilities that ICICI Life 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."],"required":true,"pdf_field":""}],"filled_by":"nominee/beneficiary"}],"deadlines":[],"applies_to":"Death claims under annuity policies including Non Return of Premium claims, Return of Premium claims, Joint life annuity claims, and JLLS/JLLSROP/JLLSROPPARTS annuity claims","attachments":["Duly filled death claim form","Copy of Annuity Certificate","Copy of Death Certificate","Copy of cancelled cheque/Passbook front page/Bank statement of Nominee bank a/c for electronic fund transfer","Nominee KYC – Recent photograph + OVD + PAN/Form 60","RTPCR report/Hospital discharge summary (if death due to COVID-19 or Accident)","First Information Report (FIR)/Police Final report (if death due to COVID-19 or Accident)","Post-mortem report (PMR) (if death due to COVID-19 or Accident)","Original Annuity Certificate/ Indemnity bond (for Return of Premium claims)","Copy of death certificate of joint life (if both annuitant and joint life expired)","Copy of joint life death certificate (for JLLS/JLLSROP/JLLSROPPARTS annuity claims where joint life has expired)","Passport or Driving license or Voter’s identity card or Job card issued by NREGA or Letter issued by National Population Register or Proof of possession of Aadhaar number (for OVD)"],"declarations":["All information provided including AADHAAR details is true, correct and accurate and ICICI Life Insurance Limited is authorized to verify and update AADHAAR details.","Payout under the policy will be strictly as per policy terms and conditions.","The particulars given in this form are true, correct and complete and the declarant takes full responsibility for their correctness.","The company is not responsible for delays or non-receipt of payment due to incorrect or incomplete information provided.","Consent is given to ICICI Life Insurance Limited to obtain additional documents or information required to settle the claim.","The declarant agrees to indemnify ICICI Life against liabilities from claims by others based on possession of policy documents."],"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/233-intimation-of-death-form"}