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Employer's Death Claim Declaration Form

This document is an employer's declaration form for a death claim. It requests information about the deceased insured member such as their name, address, date of birth, date of death, cause of death, employment details, policy details, beneficiaries, and leaves a space for the employer's signature to confirm the details. The form notes that all starred fields must be filled in for the claim to be accepted.

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Jay Taldi
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33 views2 pages

Employer's Death Claim Declaration Form

This document is an employer's declaration form for a death claim. It requests information about the deceased insured member such as their name, address, date of birth, date of death, cause of death, employment details, policy details, beneficiaries, and leaves a space for the employer's signature to confirm the details. The form notes that all starred fields must be filled in for the claim to be accepted.

Uploaded by

Jay Taldi
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Employer’s Declaration for Death Claim

*Group Policy Number (GTL)

*Group Policy Number (EDLI)

*Group Policy Holder Name


Particulars of the Insured Member:
*Full name

*Residential Address

*Designation

Nature of duties

*Date of joining the Service

*Date of Joining the Policy

*Member ID/Employee No.

Place of work Location Code:

Monthly Annual
*Last Drawn Salary

*Band / Grade
*Nature and Duration of leave taken
during 3 years

(For claims under the GTL policy)

Date of retirement (If applicable)

*Date of joining PF (For claims


under EDLI policy)

*PF Account Number (For claims


under EDLI policy)

Have you settled PF / Gratuity


benefits?

Date of withdrawal of ENTIRE PF


Amount (For claims under EDLI
policy)
*Date of birth (as per records)

*Date of death and Time of Death

*Cause of death

Chennai:+91-44-24315831/32 Bangalore:+91-80-26438638 Hyderabad:+91-40-23398480/23398481 Kochi : +91-484-2343686 Trivandrum:+91-471-3095214/246/248/2533331


Thrichur :+91-487-2444822 / 823 Coimbatore :+91-422-5368100 / 200 / 300 Delhi :+91-11-23321443/ 448 Kolkata :+91-33-22178823/ 24 Mumbai :+91-22 24954771

Toll Free: 1-600-44-6969 Write to us at metlifeindia@[Link]


Employer’s Declaration for Death Claim
*Place of death

Yes / No

* PI was on the rolls of the company


on the date of death.

Leave Details In case of difference


between Date of Death and Last
date at work.

*Beneficiary/ies of the Insured


Member, Relationship with insured,
% of shares and to whom the claim
amount is payable for the GTL
policy

*Beneficiary/ies of the Insured


Member, Relationship with insured,
% of shares and to whom the claim
amount is payable for the EDLI
policy

In respect of the above mentioned policy claim, I hereby solemnly declare that the foregoing statements
are true and correct to the best of my knowledge. I also certify that the Insured Member was an employee
of the organisation at the time of death, and also confirm that the person claiming the benefits is the
beneficiary as designated by the Insured Member and registered with us.

Signature of authorized signatory


Name & Designation
Company Seal

Date ____________________

Phone no. _____________________

* All columns have to be filled up compulsorily, without which the claim form cannot be accepted.

Chennai:+91-44-24315831/32 Bangalore:+91-80-26438638 Hyderabad:+91-40-23398480/23398481 Kochi : +91-484-2343686 Trivandrum:+91-471-3095214/246/248/2533331


Thrichur :+91-487-2444822 / 823 Coimbatore :+91-422-5368100 / 200 / 300 Delhi :+91-11-23321443/ 448 Kolkata :+91-33-22178823/ 24 Mumbai :+91-22 24954771

Toll Free: 1-600-44-6969 Write to us at metlifeindia@[Link]

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