{"id":341,"title":"Physician’s Statement – Death","purpose":"claim","insurer":{"slug":"indiafirst-life-insurance","name":"IndiaFirst Life Insurance Company Limited"},"source_pdf":"https://www.indiafirstlife.com/content/dam/ifliwebsite/in/en/download-center/claims/physicians-statement-death-individual.pdf","sha256":"8cb58cb234ad45d2220bad0c1da7b8b753cb6f559660bb8963172e8eefb39c40","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is to be filled by the attending physician to provide medical details and cause of death of the deceased for insurance claim purposes.","notes":["Use the exact labels as printed.","Fill dates in DD/MM/YYYY format.","This form is to be completed by the attending physician.","No fillable PDF fields were identified."],"title":"Physician’s Statement – Death","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of the deceased and cause of death","fields":[{"help":"","type":"text","label":"Details of the deceased (if hospital, specify the name)","options":[],"required":null,"pdf_field":""},{"help":"Select the cause of death","type":"choice","label":"Cause of death","options":["Illness","Accident","Suicide","Homicide"],"required":null,"pdf_field":""},{"help":"List causes A, B, and C in order","type":"text","label":"Antecedent causes (Morbid conditions, if any, giving rise to the above cause. State the underlying cause last. Mention only one cause in each)","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of last consultation of the illness","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of diagnosis","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of intimation to patient","options":[],"required":null,"pdf_field":""},{"help":"Duration between illness onset and death","type":"text","label":"Interval between onset and death","options":[],"required":null,"pdf_field":""},{"help":"Full address including line 1, line 2, landmark, city, state, pin code","type":"text","label":"Place of death","options":[],"required":null,"pdf_field":""},{"help":"Describe the incident details","type":"text","label":"In case of accident, suicide, or homicide, Details of the incident","options":[],"required":null,"pdf_field":""},{"help":"Indicate if inquest was conducted","type":"yes-no","label":"Inquest","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if autopsy was conducted","type":"yes-no","label":"Autopsy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide name if autopsy was done","type":"text","label":"If yes, Name of the person conducting the autopsy","options":[],"required":null,"pdf_field":""},{"help":"Autopsy or inquest findings","type":"text","label":"Findings","options":[],"required":null,"pdf_field":""}],"filled_by":"physician"},{"title":"Prior medical history and treatment","fields":[{"help":"Indicate tobacco use status","type":"choice","label":"Use of tobacco","options":["Yes","No","Don’t know"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you advised the deceased during the past 5 years, prior to the final illness?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide Name of the doctor/hospital, Address, Illness/Injury, Dates","type":"table","label":"Details of treatment by any other physician/ hospital","options":[],"required":null,"pdf_field":""}],"filled_by":"physician"},{"title":"Certification","fields":[{"help":"","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Physician's registration number","type":"text","label":"Registration no.","options":[],"required":true,"pdf_field":""},{"help":"Physician's official stamp","type":"text","label":"Stamp","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"physician"}],"deadlines":[],"applies_to":"","attachments":[],"declarations":["I hereby certify that the details provided above are true and complete to the best of my knowledge and belief."],"dropped_labels":3},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"IndiaFirst Life Insurance Company Ltd., 12th and 13th Floor, North [C] wing, Tower 4, Nesco IT Park, Nesco Center, Western Express Highway, Goregaon (East), Mumbai – 400063","label":"Claims documents submission address","level":null,"hours":null,"applies_to":"life","source_url":"https://www.indiafirstlife.com/claims/claims-overview","quote":"ntative will reach out to you soon to guide you through our life insurance plans that fit your life goals\nHome\nClaims - IndiaFirst Life Insurance\nClaims Overview\nLife Insurance Claim Process\nAt IndiaFirst Life, we stand firmly with our customers in their hour of grief. We provide a streamlined claim registration and settlement process, ensuring a worry-free future for our customers. With a focus on efficiency","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"claims.support@indiafirstlife.com","label":"Claims support email","level":null,"hours":null,"applies_to":"life","source_url":"https://www.indiafirstlife.com/claims/claims-overview","quote":"rstlife.com/claims/claims-overview/register-claim-online\n\"\nEmail:\nShare soft copies of all the mandatory documents at '\nclaims.support@indiafirstlife.com\n'\nCall:\nContact us at 1800-209-8700 for assistance. Our representative will guide you through the claim process registr","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-209-8700","label":"Claims assistance phone","level":null,"hours":null,"applies_to":"life","source_url":"https://www.indiafirstlife.com/claims/claims-overview","quote":"\"\nEmail:\nShare soft copies of all the mandatory documents at '\nclaims.support@indiafirstlife.com\n'\nCall:\nContact us at 1800-209-8700 for assistance. Our representative will guide you through the claim process registration.\nVisit Us:\nDrop soft/hard copi","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"url","value":"https://www.indiafirstlife.com/claims/claims-overview/register-claim-online","label":"Register your claim online","level":null,"hours":null,"applies_to":"life","source_url":"https://www.indiafirstlife.com/claims/claims-overview","quote":"Claim Process\nClaim Documents\nFAQs for Claim\nStep 1. Claim Registration\nAnswer\nOnline:\nRegister your claim online at \"\nhttps://www.indiafirstlife.com/claims/claims-overview/register-claim-online\n\"\nEmail:\nShare soft copies of all the mandatory documents at '\nclaims.support@indiafirstlife.com\n'\nCall:\nContact us at","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/indiafirst-life-insurance/341-physicians-statement-death"}