{"id":245,"title":"Group Credit Life (Lender-Borrower) – Claim Statement Form – Non-MFI","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/Claim_Statement_Form_Non_MFI.pdf","sha256":"ee4153d9ce66239b4683926239ebdd8fa4e877e0fbc1e20bba7986311eb54a30","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is for submitting a death claim under the Group Credit Life insurance policy by the nominee or claimant of the deceased member.","notes":["Form must be filled by the Nominee; if Nominee is minor, Guardian/Appointee must fill with Guardianship Certificate and age proof","If Nominee is deceased, Legal Heir must provide additional documents such as Nominee Death Certificate with Succession Certificate, Will, Notarised Indemnity with Affidavit and No Objection Certificate from other heirs, or Final Court order","Payouts are processed electronically to bank accounts as per regulatory requirements","IFSC code responsibility lies with customer; RTGS and NEFT IFSC codes may differ","In case of any demand or favour asked by anyone for claim processing, report immediately to claimsupport@icicilife.com","Use original documents where specified","Communication or permanent address should match address proof provided","Claimant must sign or affix thumb impression","Witness signature and details required","Beware of spurious/fraud phone calls; IRDAI is not involved in selling policies or announcing bonuses"],"title":"Group Credit Life (Lender-Borrower) – Claim Statement Form – Non-MFI","submit":{"to":"Claims department, ICICI Life Insurance Limited","how":"post / e-mail / upload / in person (not explicitly specified)","address":""},"purpose":"claim","sections":[{"title":"Mandatory Documents Checklist","fields":[{"help":"","type":"text","label":"Master Policy number(s)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Master Policyholder","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Member Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Member ID/Loan Account","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"MPH Branch name & code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Employee name & Code","options":[],"required":null,"pdf_field":""},{"help":"Attach one officially valid address proof such as Aadhar Card, Passport, Driver's License, Voters ID","type":"checkbox","label":"Claimant address proof*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach one officially valid photo ID proof","type":"checkbox","label":"Claimant photo identity proof*","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach cancelled cheque or bank statement or passbook copy","type":"checkbox","label":"Copy of cancelled cheque / bank statement / bank passbook of the claimant**","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Required if death due to unnatural causes","type":"checkbox","label":"First Information Report (FIR) from the police authority","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Required if death due to unnatural causes","type":"checkbox","label":"Inquest Panchnama Report","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Required if death due to unnatural causes","type":"checkbox","label":"Final police investigation report","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Required if death due to unnatural causes","type":"checkbox","label":"Post Mortem Report (PMR) issued by the hospital","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Required if death due to unnatural causes","type":"checkbox","label":"Viscera / Chemical examination report","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach if available","type":"checkbox","label":"Newspaper Cutting, if any","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach if applicable","type":"checkbox","label":"Driving License (of the Life Assured driving the vehicle in case of death due to a road accident)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach if available","type":"checkbox","label":"Hospitalization / treatment records if any","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach if applicable","type":"checkbox","label":"Medico-legal cause of death","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach if available","type":"checkbox","label":"Past medical records and treatment papers","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach all hospitalization related documents","type":"checkbox","label":"All hospitalization records of the Life Assured such as: Admission form, Indoor Case Papers (ICPs), Discharge summary, Diagnostic test reports such as USG, Pathology / Lab reports etc.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"nominee/claimant"},{"title":"Details of Life Assured","fields":[{"help":"Enter LAN number","type":"text","label":"LAN NO (MANDATORY)","options":[],"required":true,"pdf_field":""},{"help":"Enter policy number(s)","type":"text","label":"Policy number(s)","options":[],"required":null,"pdf_field":""},{"help":"Enter full name with Mr./Ms. prefix","type":"text","label":"Name of Life Assured","options":[],"required":true,"pdf_field":""},{"help":"Enter father's name","type":"text","label":"Father's Name","options":[],"required":null,"pdf_field":""},{"help":"Enter date of death in DD/MM/YYYY format","type":"date","label":"Date of Death","options":[],"required":true,"pdf_field":""},{"help":"Tick one and specify if Other","type":"choice","label":"Place of Death","options":["Hospital","Clinic","Residence","Office","Other"],"required":true,"pdf_field":""},{"help":"Tick one","type":"choice","label":"Nature of Death","options":["Medical","Natural","Accident","Murder","Suicide"],"required":true,"pdf_field":""},{"help":"Specify cause of death","type":"text","label":"Cause of Death","options":[],"required":null,"pdf_field":""},{"help":"Enter name of treating doctor or hospital","type":"text","label":"Name of treating doctor / Hospital","options":[],"required":null,"pdf_field":""},{"help":"Tick all applicable","type":"checkbox","label":"Cause of Death / Nature of Illness / Habit (Please tick)","options":["Hypertension","Diabetes","Heart disease","Liver disease","Kidney disease","Cancer","Others"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Any hospitalisation / Illness in last 5 yrs.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter date if applicable","type":"date","label":"Date of diagnosis of illness","options":[],"required":null,"pdf_field":""},{"help":"Fill columns: Policy No., Company Name/TPA, Sum Assured, Status (Active/Lapsed/Applied/Matured)","type":"table","label":"Other Insurance details: (Life/Mediclaim/Health)","options":[],"required":null,"pdf_field":""}],"filled_by":"nominee/claimant"},{"title":"Details of Claimant","fields":[{"help":"Enter full name with Mr./Ms. prefix","type":"text","label":"Claimant Name","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Address should match address proof provided","type":"text","label":"Communication Address","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter telephone number with STD code","type":"phone","label":"Telephone with STD code","options":[],"required":null,"pdf_field":""},{"help":"Enter alternate mobile number if any","type":"phone","label":"Alternate Mobile number","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"WhatsApp opt in","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify convenient time for contact","type":"text","label":"Convenient time to call","options":[],"required":false,"pdf_field":""},{"help":"Enter postal code","type":"text","label":"Pincode","options":[],"required":null,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter country","type":"text","label":"Country","options":[],"required":null,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"Nationality","options":[],"required":null,"pdf_field":""},{"help":"Enter permanent address","type":"text","label":"Permanent address","options":[],"required":null,"pdf_field":""},{"help":"Tick one and specify if Others","type":"choice","label":"Relation with the Life Assured","options":["Spouse","Children","Parents","Others"],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Politically exposed person","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter claimant's bank account number","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"Enter name as per bank account","type":"text","label":"Account Holder Name","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number linked to bank account","type":"phone","label":"Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name and branch","type":"text","label":"Bank Name & Branch","options":[],"required":true,"pdf_field":""},{"help":"Tick Yes or No; if Yes, fill FATCA/CRS certification","type":"yes-no","label":"US Person","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick one","type":"choice","label":"Account Type","options":["Savings","Current","NRO","NRE"],"required":true,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR code if available","type":"text","label":"MICR","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN details","type":"text","label":"Claimant's PAN details","options":[],"required":false,"pdf_field":""},{"help":"Sign or affix thumb impression","type":"signature","label":"Signature / Thumb impression of the claimant","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter witness name and signature","type":"text","label":"Name & signature of the witness","options":[],"required":true,"pdf_field":""},{"help":"Specify relation with claimant","type":"text","label":"Relation with claimant","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration and Authorisation","fields":[{"help":"Read and agree to all declarations and authorisations listed","type":"text","label":"Declaration and Authorisation","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Authorisation Letter","fields":[{"help":"Enter policy number(s)","type":"text","label":"Life Insurance Policy Number(s)","options":[],"required":true,"pdf_field":""},{"help":"Enter claimant's full name","type":"text","label":"Name of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Witness to sign","type":"signature","label":"Witness Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter witness address","type":"text","label":"Address of Witness","options":[],"required":false,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant/nominee"}],"deadlines":[],"applies_to":"death claims under Group Credit Life (Lender-Borrower) policies","attachments":["Copy of death certificate of the Life Assured, issued by government authority","Claimant address proof (e.g. Aadhar Card, Passport, Driver's License, Voters ID)","Claimant photo identity proof","Duly filled and signed payout mandate form with bank account details of the claimant","Copy of cancelled cheque / bank statement / bank passbook of the claimant","First Information Report (FIR) from the police authority (if death due to unnatural causes)","Inquest Panchnama Report (if death due to unnatural causes)","Final police investigation report (if death due to unnatural causes)","Post Mortem Report (PMR) issued by the hospital (if death due to unnatural causes)","Viscera / Chemical examination report (if death due to unnatural causes)","Newspaper Cutting, if any","Driving License (of the Life Assured driving the vehicle in case of death due to a road accident)","Hospitalization / treatment records if any","No objection certificate/ loan credit account statement from the institution/bank/lender from where the loan was availed","Medico-legal cause of death (if applicable)","Past medical records and treatment papers","All hospitalization records such as Admission form, Indoor Case Papers (ICPs), Discharge summary, Diagnostic test reports","Treating Doctor Certificate","Medical Hospital Attendant Certificate (MHAC) if death was at home","Employer certificate (if Life Assured was salaried individual)","Authorisation letter signed by claimant and witness"],"declarations":["All details filled are true and correct to the best of my knowledge and belief","False or untrue statements or concealment of material facts will forfeit claim rights","Submission of this form does not guarantee claim processing","I consent to ICICI Life processing payment of outstanding loan amount to master policyholder","Payouts will be as per policy terms and conditions","I authorise medical and government institutions to share treatment information with ICICI Life","I will submit all documents required for claim evaluation","A photocopy of this declaration is valid","I authorise ICICI Life to share and obtain information/documents with third parties for claim processing"],"dropped_labels":15},"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/245-group-credit-life-lender-borrower-claim-statement-form-non-mfi"}