{"id":643,"title":"Claim Form A - Individual Death Claim","purpose":"claim","insurer":{"slug":"indusind-nippon-life-insurance","name":"IndusInd Nippon Life Insurance Company Limited"},"source_pdf":"https://www.indusindnipponlife.com/documents/34625/224924/claim-form-a-individual-death-claim.pdf","sha256":"33a8facd89f5dc6c0aa45f488ee572255c46f7f969da67f7707c3c35f935f923","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the claimant or nominee to claim death benefits under an individual life insurance policy after the death of the life assured.","notes":["All answers to be in Block Letters - No Dots and Dashes.","Cancelled cheque should bear the name of the nominee/account holder and IFSC/RTGS/NEFT Code.","If cancelled cheque details are not available, a recent bank statement of the same bank account must be submitted.","Bank account number should be clear and visible; do not cross on account number.","Payment will be credited only through direct transfer to the given bank account.","Use original documents as attachments.","Beware of spurious phone calls and fraudulent offers; IRDAI does not involve in such activities."],"title":"Claim Form A - Individual Death Claim","submit":{"to":"IndusInd Nippon Life Insurance Company Limited","how":"","address":"Unit Nos.401B, 402, 403 & 404, 4th Floor, Inspire-BKC, G Block, BKC Main Road, Bandra Kurla Complex, Bandra East, Mumbai-400051, India"},"purpose":"claim","sections":[{"title":"Details of the Life Assured and Policy","fields":[{"help":"Enter full name in block letters without dots or dashes","type":"text","label":"Name of the Deceased Life Assured","options":[],"required":true,"pdf_field":""},{"help":"Enter the policy number","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"Enter policy start date","type":"date","label":"Date of Commencement","options":[],"required":true,"pdf_field":""},{"help":"Enter the sum assured amount","type":"amount","label":"Sum Assured","options":[],"required":true,"pdf_field":""},{"help":"Enter the insurance company name","type":"text","label":"Name of the Company","options":[],"required":true,"pdf_field":""},{"help":"List other policies if any","type":"text","label":"Mention full particulars of all other Policies on the Life of the deceased taken with other companies which has now resulted into claim by death","options":[],"required":false,"pdf_field":""},{"help":"Provide full name and address","type":"text","label":"Name and address of the doctor/hospital who treated the Life Assured during his/her last illness","options":[],"required":false,"pdf_field":""},{"help":"Provide full name and address","type":"text","label":"Name & Address of Business/Employer of Life Assured","options":[],"required":false,"pdf_field":""},{"help":"Describe the last illness","type":"text","label":"Details of Last lllness","options":[],"required":false,"pdf_field":""},{"help":"State the cause of death","type":"text","label":"Cause of Death of Life Assured","options":[],"required":true,"pdf_field":""},{"help":"Enter date of death","type":"date","label":"Date of Death of Life Assured","options":[],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age at Death","options":[],"required":true,"pdf_field":""},{"help":"Enter client number if available","type":"text","label":"Client Number","options":[],"required":false,"pdf_field":""},{"help":"Select the claimant's title","type":"choice","label":"Nature of title under which the claim for Policy Monies is submitted: Nominee / Assignee/ Trustee / others","options":["Nominee","Assignee","Trustee","others"],"required":true,"pdf_field":""},{"help":"Specify relationship","type":"text","label":"Relationship of Claimant to Life Assured","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or nominee"},{"title":"Claimant Details and Contact Information","fields":[{"help":"Enter full name in block letters","type":"text","label":"Name of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"Provide full address including pin code","type":"text","label":"Correspondence Address/ Usual place of residence","options":[],"required":true,"pdf_field":""},{"help":"Select residential status and specify country if NRI","type":"choice","label":"Residential status: Indian        Non Resident Indian (NRI)        Country, if NRI _________________________________","options":["Indian","Non Resident Indian (NRI)"],"required":true,"pdf_field":""},{"help":"Provide tax residence details if applicable","type":"text","label":"Residence for Tax purposes in Jurisdiction(s) outside India (To be filled by the Nominee / Claimant)","options":[],"required":false,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email Address","options":[],"required":false,"pdf_field":""},{"help":"Enter telephone STD or ISD code","type":"text","label":"STD ISD Code","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or nominee"},{"title":"Bank Account Details for Payment","fields":[{"help":"Enter name exactly as per bank records","type":"text","label":"Name as per Bank Records","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC/RTGS/NEFT code","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Enter branch name","type":"text","label":"Branch Name","options":[],"required":false,"pdf_field":""},{"help":"Attach cancelled cheque leaf with name and IFSC code visible","type":"attachment","label":"Attach Cancelled Cheque Here","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or nominee"},{"title":"Declarations and Signatures","fields":[{"help":"Sign to declare correctness of information","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Name of witness if claimant is not nominee","type":"text","label":"Witness Name","options":[],"required":false,"pdf_field":""},{"help":"Witness signature if applicable","type":"signature","label":"Signature of the Witness","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or nominee"},{"title":"Claimant Declaration for Non-English Speakers","fields":[{"help":"Signature of person completing form for claimant","type":"signature","label":"Signature of the CCE","options":[],"required":false,"pdf_field":""},{"help":"Date branch received form","type":"date","label":"Date of Claim form Received at Branch","options":[],"required":false,"pdf_field":""},{"help":"Email of person completing form","type":"email","label":"E-mail ID of the CCE","options":[],"required":false,"pdf_field":""},{"help":"Contact number of person completing form","type":"phone","label":"Contact No. of the CCE","options":[],"required":false,"pdf_field":""},{"help":"SAP code of person completing form","type":"text","label":"SAP Code of the CCE","options":[],"required":false,"pdf_field":""},{"help":"Name of branch customer care executive","type":"text","label":"Name of the Branch CCE","options":[],"required":false,"pdf_field":""},{"help":"Claimant's contact number","type":"phone","label":"Claimant Contact No.","options":[],"required":false,"pdf_field":""},{"help":"Name and relationship of claimant","type":"text","label":"Claimant Name/Relationship","options":[],"required":false,"pdf_field":""}],"filled_by":"person completing form for claimant if claimant cannot read/write English"},{"title":"Payment Option Selection","fields":[{"help":"Select one payment option","type":"choice","label":"Please indicate how you would like to receive the benefits.","options":["Entire amount as lumpsum","Entire amount as Annuity","Part as annuity, part as Lumpsump"],"required":true,"pdf_field":""}],"filled_by":"claimant or nominee"},{"title":"Declaration by Declarant (if applicable)","fields":[{"help":"Name of person completing form for claimant","type":"text","label":"Declarant Name","options":[],"required":false,"pdf_field":""},{"help":"Signature of declarant","type":"signature","label":"Signature of Declarant","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":false,"pdf_field":""}],"filled_by":"declarant (not employee/advisor of insurer)"}],"deadlines":[],"applies_to":"Individual death claims under life insurance policies","attachments":["Original Policy Schedule/Document","Original Death certificate","AML/KYC Document of Claimant","Payout form along with cancelled cheque leaf/Bank passbook copy"],"declarations":["The claimant declares that the statements made in this claim form are true and correct to the best of their knowledge and belief.","The claimant authorizes any doctor, hospital, employer, police or related authorities to provide information to the insurer for claim consideration.","If the claimant cannot read/write English, the person completing the form declares that the form contents were explained and understood by the claimant.","The declarant (if any) confirms they are not an employee or advisor of the insurer."],"dropped_labels":2},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Claims Department, Office no. 701 & 702, 7th floor, Silver Metropolis, Off Western Express Highway, Goregaon East, Mumbai – 400063","label":"Claims Department postal address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.indusindnipponlife.com/claims","quote":"nearest\nINLIC branch\nfor in-person assistance.\nEmail scanned documents at\nclaims@indusindnipponlife.com\n.\nCourier to\n: Claims Department, Office no. 701 & 702, 7th floor, Silver Metropolis, Off Western Express Highway, Goregaon East, Mumbai – 400063.\nIn case of assistance, contact us on\n1800 102 3330\nor email us on\ncustomerservice@indusindnipponlife.com\nTrack A Claim","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"claims@indusindnipponlife.com","label":"Claims Department email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.indusindnipponlife.com/claims","quote":"ou Can Register your claim easily:\nVisit your nearest\nINLIC branch\nfor in-person assistance.\nEmail scanned documents at\nclaims@indusindnipponlife.com\n.\nCourier to\n: Claims Department, Office no. 701 & 702, 7th floor, Silver Metropolis, Off Western Express Highway, Gore","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 102 3330","label":"Claims Helpline","level":null,"hours":null,"applies_to":"all","source_url":"https://www.indusindnipponlife.com/claims","quote":"r, Silver Metropolis, Off Western Express Highway, Goregaon East, Mumbai – 400063.\nIn case of assistance, contact us on\n1800 102 3330\nor email us on\ncustomerservice@indusindnipponlife.com\nTrack A Claim\nFile a Claim\nLiving Benefits / Rider Claims\nGet the","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/indusind-nippon-life-insurance/643-claim-form-a-individual-death-claim"}