{"id":657,"title":"Group Insurance Death Claim Form (Employer - Employee)","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_Death_Claim_Form_(Employer_-_Employee).pdf","sha256":"6d4de82ee2769ee04b3ab0275c25d2f50079a8461563d06a156d156266b09878","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used to claim death benefits under a group insurance policy. It is filled by the employer on behalf of the deceased employee.","notes":["Complete the form in duplicate and retain a copy for your records.","All sections must be completed.","Beneficiary details form must accompany this form.","The documents listed are indicative; additional documents may be requested.","Use original documents for submission.","The office use section is for company staff only."],"title":"Group Insurance Death Claim Form (Employer - Employee)","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":"Company 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":""},{"help":"","type":"phone","label":"Phone Number","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Member Details","fields":[{"help":"Enter full name with title","type":"text","label":"Name of Employee (Title) (Surname) (First Name) (Middle Name)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Residential Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone Number","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":"DD/MM/YYYY format","type":"date","label":"Date of Death","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":""},{"help":"","type":"text","label":"Employee ID.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Category & Salary Grade","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Last Drawn PF based Salary","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 Death","options":[],"required":null,"pdf_field":""},{"help":"If 'Others', provide details with cause of death","type":"choice","label":"Type","options":["Natural","Accidental","Suicide","Murder","Others"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Cause of Death","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place of Death with address","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Additional Details (For Family Benefit Claims of Insured Family Members Only)","fields":[{"help":"Enter full name with title","type":"text","label":"Name of the Nominee (Title) (Surname) (First Name) (Middle Name)","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":"Relationship to member","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Benefit Details","fields":[{"help":"","type":"text","label":"Bank Account Details (mandatory) Name of Account Holder","options":[],"required":true,"pdf_field":""},{"help":"Provide bank account number for benefit payment","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":"Address to which cheque and confirmation of payment should be sent: Contact Person","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-mail Address","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Declaration and Authority to Pay Claim","fields":[{"help":"Place where form is signed","type":"text","label":"Signed at","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signatory's designation","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Signatory's name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or authorized signatory"},{"title":"Claimant's Aadhaar Consent","fields":[{"help":"Date of consent","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature/Thumb impression of the claimant","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Scribe Details - Declaration by the person filling this form","fields":[{"help":"If form is filled by scribe or signed in vernacular","type":"text","label":"Full name of scribe","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact no","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relation with claimant","options":[],"required":null,"pdf_field":""}],"filled_by":"scribe (if applicable)"}],"deadlines":[],"applies_to":"death claims under group insurance policies","attachments":["Original death certificate issued by the Municipal Authority","Last attending doctor's certificate stating the exact cause of death","If death has occurred in a hospital, all case history papers","If the death is due to an accident or any other unnatural cause, a certified copy of the FIR filed with the Police authorities","A certified copy of the Post Mortem Report/Autopsy Report","A certified copy of the Driving License if death occurred while driving","Beneficiary nomination form if claim is payable to the beneficiary","Proof of relationship with member (for family benefit claims only)","Leave Records"],"declarations":["The deceased was a legitimate member eligible for insurance cover on the date of death.","The deceased joined employment/the group on the stated date and was actively at work/in good health on the cover commencement date.","Payment of claim proceeds will be full and final discharge of Kotak Mahindra Life Insurance Company's liability for that member.","Consent to submit Aadhaar for identity verification and KYC purposes only.","Acknowledgement that Aadhaar details will not be used for other purposes unless required by law.","During offline verification, information such as Name, Age, Gender, and Address may be verified.","The claimant may submit other valid identity documents instead of Aadhaar."],"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/657-group-insurance-death-claim-form-employer-employee"}