{"id":560,"title":"Claim Intimation form – Critical Illness / Terminal Illness / De-generative Illness","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/claim-intimation-form-critical-illness-individual.pdf","sha256":"6f4240a2a967ae1ab96d1ac165e63d1df3b1d7acfa91cd0727024463d36258a0","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the policyholder or claimant to intimate a claim for critical illness, terminal illness, or degenerative illness under an individual life insurance policy.","notes":["All claim payments will be made through electronic fund transfer only.","Issuance of this form does not amount to admission of any claim or liability by the insurer.","Attach the fully completed form along with Treating Doctors Certificate issued by appropriate authority.","IndiaFirst does not demand any fees to process claims; contact customer service if such demand is made.","It is mandatory to provide a cancelled cheque and copy of bank pass book & account statement for payout.","Content of this form and its particulars should be explained in vernacular language if claimant signs in vernacular or thumb impression.","Use original documents as listed in mandatory documents section.","The company may call for additional documents or information depending on the claim."],"title":"Claim Intimation form – Critical Illness / Terminal Illness / De-generative Illness","submit":{"to":"Kindly mail this completely filled form along with the documents","how":"mail","address":"customer.first@indiafirstlife.com"},"purpose":"claim","sections":[{"title":"Life Assured’s details","fields":[{"help":"","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy number:","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of birth:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation:","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","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":"email","label":"E Mail ID:","options":[],"required":null,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"PAN No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile:","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or policyholder"},{"title":"Nature of Illness Suffered","fields":[{"help":"Tick if applicable","type":"checkbox","label":"Heart attack","options":["Heart attack"],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Major Organ or Bone Marrow Transplant  (as recipient)","options":["Major Organ or Bone Marrow Transplant  (as recipient)"],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Open Heart Replacement or Repair of Heart Valves","options":["Open Heart Replacement or Repair of Heart Valves"],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Motor Neurone Disease with Permanent Symptoms","options":["Motor Neurone Disease with Permanent Symptoms"],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Stroke resulting in Permanent Symptoms","options":["Stroke resulting in Permanent Symptoms"],"required":null,"pdf_field":""},{"help":"Specify other illness if not listed","type":"text","label":"Other (Please Specify)","options":[],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Kidney Failure requiring regular dialysis","options":["Kidney Failure requiring regular dialysis"],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Coma with Severity","options":["Coma with Severity"],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Open Chest CABG (Coronary Artery Bypass Graft Surgery)","options":["Open Chest CABG (Coronary Artery Bypass Graft Surgery)"],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Cancer","options":["Cancer"],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Alzheimer’s Disease","options":["Alzheimer’s Disease"],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Permanent Paralysis of limbs","options":["Permanent Paralysis of limbs"],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Parkinson’s","options":["Parkinson’s"],"required":null,"pdf_field":""},{"help":"Tick if applicable; refer to policy document for definition","type":"checkbox","label":"Terminal Illness*","options":["Terminal Illness*"],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Any other form of Dementia","options":["Any other form of Dementia"],"required":null,"pdf_field":""}],"filled_by":"claimant or policyholder"},{"title":"Details of Illness/Ailment (To be completed by Treating Doctor)","fields":[{"help":"","type":"text","label":"Name of Patient","options":[],"required":true,"pdf_field":""},{"help":"Include duration of illness","type":"text","label":"Presenting complaints of illness / disease (With duration)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name and Address of Hospital","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Final diagnosis","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Past Medical History (Related / Unrelated with current illness along with duration)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name and Degree of Treating doctor","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of consultation / Admission","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Treatment Given","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Admission (If Hospitalised)","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Discharge (If Hospitalised)","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Has the patient ever suffered with this or any similar condition before the present episode?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"Employment/Occupation Details","fields":[{"help":"Select one","type":"choice","label":"Occupation","options":["Salaried","Business","Student","Housewife","Retired"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Company / Business","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of the Company / Business","options":[],"required":null,"pdf_field":""},{"help":"Describe main job duties","type":"text","label":"List of Job Duties","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you currently Employed","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"If “No”, than last attended employment date","options":[],"required":null,"pdf_field":""},{"help":"Columns: Dates From, Dates To, Reason as per Medical Certificate / Employer, Mediclaim Benefit Availed (Yes/No), Leave Application (Yes/No) (If Yes provide TPA Name)","type":"table","label":"Please Give the Details of the Medical / Sick Leave taken in Last 5 Years","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or policyholder"},{"title":"Particulars of other Health Insurance / Mediclaim Policies held by the Life Assured","fields":[{"help":"","type":"text","label":"Name of the company / TPA","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Policy Issue date","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Sum assured","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Claim Raised (Yes / No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Illness / Disease","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or policyholder"},{"title":"Declaration and Authorisation","fields":[{"help":"","type":"text","label":"Name of Claimant/Policy holder","options":[],"required":true,"pdf_field":""},{"help":"Phone or email","type":"text","label":"Contact Details","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Name and Signature of Claimant/Policy holder","options":[],"required":true,"pdf_field":""},{"help":"Place where form is signed","type":"text","label":"Location","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or policyholder"},{"title":"Mode of Payment","fields":[{"help":"","type":"text","label":"Bank name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"Bank account number for payout","type":"text","label":"Account number","options":[],"required":true,"pdf_field":""},{"help":"Savings/Current etc.","type":"text","label":"Type of account","options":[],"required":true,"pdf_field":""},{"help":"Indian Financial System Code","type":"text","label":"IFSC code","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"MICR Code","options":[],"required":false,"pdf_field":""},{"help":"Name exactly as in bank records","type":"text","label":"Name as per Bank Records","options":[],"required":true,"pdf_field":""},{"help":"Select payout mode","type":"choice","label":"Mode selected would be used by the company to make payout(s) to the Claimant. Payout would be in accordance and subject to the terms and conditions of the policy.","options":["Direct Credit (Bank of Baroda only)","NEFT / RTGS"],"required":true,"pdf_field":""}],"filled_by":"claimant or policyholder"},{"title":"Witness Authorization (if applicable)","fields":[{"help":"","type":"text","label":"Name of Witness","options":[],"required":null,"pdf_field":""},{"help":"Phone or email","type":"text","label":"Contact Details","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Name and Signature of Witness","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relationship with Claimant","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""}],"filled_by":"witness"}],"deadlines":[],"applies_to":"Critical Illness / Terminal Illness / De-generative Illness claims under individual life insurance policies","attachments":["Treating Doctors Certificate mentioning the First Consultation With Exact Diagnosis and Date of Diagnosis","ECG, Cardiac Enzyme Test Report (for Heart attack)","Investigation/Diagnostic reports leading to the Diagnosis of the ailment suffered","Histopathology / Biopsy Report (for Cancer)","All Hospitalization documents including discharge summary, Admission Notes and all investigation reports","Diagnosis of Original Report, Surgical Summary, Discharge Card (for Major Organ Transplant)","Self attested Copy of bank pass book of Policy Holder along with cancelled cheque with preprinted name","KYCs of the Life Assured"],"declarations":["I am the rightful claimant and the details provided are true and correct to the best of my knowledge.","I authorize any hospital, medical practitioner, employer, insurance company, government organization or other institution to provide IndiaFirst with any medical or employment information related to me.","I understand that IndiaFirst may use this information to process my claim.","I declare that the company shall not be responsible for non-credit or delay in credit of my bank account due to incorrect details provided by me.","I take sole responsibility for the correctness of my bank account details provided in this form."],"dropped_labels":1},"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/560-claim-intimation-form-critical-illness-terminal-illness-de-generative-illness"}