{"id":651,"title":"Group Insurance Claim Form For Critical Illness Claims","purpose":"claim","insurer":{"slug":"kotak-mahindra-life-insurance","name":"Kotak Mahindra Life Insurance Company Limited"},"source_pdf":"https://www.kotaklife.com/assets/images/uploads/how_do_i/Group_Insurance_Claim_Form_For_Critical_Illness_Claims2.pdf","sha256":"9bb1c62949b47135a7893e49aedcb13e2ad5b457a2e3abcb53da333fd4925f13","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by members or policyholders to claim benefits for critical illness under a group insurance plan.","notes":["Complete the form in duplicate and retain a copy for your records.","All sections must be completed.","Attach primary documentation required for CI claims as listed.","Beneficiary details form must accompany this form.","The bank account details are mandatory.","The form must be signed by an authorised person with designation."],"title":"Group Insurance Claim Form For Critical Illness Claims","submit":{"to":"Kotak Mahindra Life Insurance Company Ltd.","how":"","address":"Registered Office: 3rd Floor, Plot #C-12, G- Block, BKC, Bandra (E), Mumbai-400 051, Maharashtra, India.\nCorporate Office: 9th Floor, Intellion Square, Building No. 4 Infinity IT Park, Gen. A K Vaidya Marg, Malad (E), Mumbai - 400 097\nEmail: Kli.claimsmitra-group@kotak.com"},"purpose":"claim","sections":[{"title":"Plan Details","fields":[{"help":"","type":"text","label":"Name of Plan","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Holder Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Member Details","fields":[{"help":"Include Title, Surname, First Name, Middle Name","type":"text","label":"Name of Member","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of joining","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Cover commenced date","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Member ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Residential Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Claim Event Details (For Death Claims Only)","fields":[{"help":"DD/MM/YYYY format","type":"date","label":"Date of Diagnosis of CI","options":[],"required":null,"pdf_field":""},{"help":"Specify the critical illness diagnosed","type":"text","label":"Nature of CI","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Hospital where treatment was taken","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Benefit Details","fields":[{"help":"Select who will receive the benefit","type":"choice","label":"Benefit Payable to","options":["Policy holder","Beneficiary","Member"],"required":null,"pdf_field":""},{"help":"Provide bank account details for payment","type":"text","label":"Bank Account Details(mandatory)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of Account Holder","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Account No","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of Bank and Branch","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Contact Person","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email Address","options":[],"required":null,"pdf_field":""},{"help":"Address to which cheque and confirmation of payment should be sent","type":"text","label":"Postal Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Outstanding Loan Amount","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Loan Amount","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Annual Salary","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Cover Amount","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Declaration and Authority to Pay Claim","fields":[{"help":"Name of the person making the declaration","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Designation of the person making the declaration","type":"text","label":"Designation","options":[],"required":true,"pdf_field":""},{"help":"Signature of the authorised person","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact No","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-mail Add","options":[],"required":null,"pdf_field":""},{"help":"Place where the form is signed","type":"text","label":"Signed at","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"this day of","options":[],"required":null,"pdf_field":""}],"filled_by":"authorised signatory"}],"deadlines":[],"applies_to":"Critical Illness claims under group insurance plans","attachments":["Beneficiary details form to accompany this form","Medical Records (Consultation Notes, Treatment Records, Admission Notes, Hospital Indoor Case Papers, Discharge/Summary, Investigation Reports etc.)","Copy of Bank Passbook or Cancelled Cheque, Bank Statement showing Account Number, IFSC Code, and Account Holder's Name for verification","Proof of membership (e.g. Certified copy of the latest Pay slip, certified copy of membership card etc) and valid KYC documents"],"declarations":["The person whose illness gave rise to this claim is legitimately ill and was a member of the Plan on the date of diagnosis.","The person joined employment/the Group on the stated date and was actively at work/in good health on the date of commencement of cover.","Payment of the claim proceeds will represent full and final discharge of Kotak Mahindra Life Insurance Company's liability under the Plan."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"kli.claimsmitra@kotak.com","label":"Claims Department Email","level":1,"hours":null,"applies_to":"life","source_url":"https://www.kotaklife.com/assets/images/uploads/how_do_i/Kotak_Signature_Legacy_UIN_107N135V01_Policy_Document.pdf","quote":"to the Insurer online from the Insurer’s website; and the Claimant can also write to the Insurer’s claims department at kli.claimsmitra@kotak.com.\nProcedure and Documentation for Death Benefit claims:\nThe Claimant shall submit the claim intimation form along with n","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/kotak-mahindra-life-insurance/651-group-insurance-claim-form-for-critical-illness-claims"}