1. Details of the Claimant - ICICI Prudential Life Insurance

CLAIMANT’S STATEMENT(Format AB: Acciden tal Death Claim)Note: Only the claimant i.e. the person entitled to receive the policy monies as stated under the Policyshould fill & sign this form.Policy Number ________________________Date ________________1. Details of the Claimant:i. Nameii. Ageiii. Residential Address & Telephone No.iv. Relationship with the deceased lifeassuredv. Nature of title to the Policy monies Nominee / Assignee / Executor /Administrator / Trustee / other2. Details of the death of Life Assured:i. Nameii. Date & time of deathiii. Place of deathiv. Cause of deathv. Name, address & tel. no. of the doctor whodeclared the deathvi. Date and time of cremation / burialvii. Age of the life assured at the time of deathviii. Nature & period of last illness (from- to)ix. Last employer’s name, tel no & addressx. Designation at work placexi. Last residential addressxii. Full name of the deceased’s father3. Details of the accidenti. Date & time of the accidentii. How did the accident occur?iii. People involved in this accidentiv. Name & address of Police Station whereFIR has been lodgedv. Name and address of hospital where PostMortem has been performedvi. Date of Post Mortem conducted

4. Did the Life Assured suffer from any ongoing or recurrent health problems?YES/NO. If yes please furnish the details given below.i. Nature of illness/ailmentii.iii.Duration of the illness/ailmentName of the doctor/hospital wheretreatment was given5. Please give the name, address & telephone no of:i. Life Assured's usual / family medicalconsultantii. Other doctors Life Assured consultedprior to death6. Particulars of other policies on the life of the deceased:Sr. InsuranceCompanyPolicy No. SumAssuredCommencement datei.ii.Riders7. Any other information, which you consider, would be useful for considering theclaim under the policy.____________________________________________________________________________________________________________________________________________________________I, _____________________________________ do hereby declare that the statement madeherein above is true in each & every respect. I hereby authorize any medical attendant ordoctor of the Life Assured who had attended to the above named Life Assured oremployer/business associate of the Life Assured to furnish any information or details asto the state of health and habits of the deceased, to the Company, within his knowledgebefore or after this policy was issuedSigned at _______________ this __________ day of _________________20 ______________________________________________(Signature/Thumb impression of the claimant)Full Name: ______________________Address:_________________________________________________________________________Tel No. _________________________________________________________(Signature of Witness)Name:__________________________Designation:_____________________Relationship with the claimant_____Address ________________________Tel.No. ________________________DECLARATION FOR SIGNING IN VERNACULAR LANGUAGE OR AFFIXING THUMBIMPRESSION:I certify that I have read out the contents of this statement to Mr./Mrs.________________________________________ & he/she has understood the same. I also certify thatMr./Mrs. ____________________________________ has signed/affixed his/her thumbimpression / signature in vernacular language in my presence after I have explained theabove contents to him/her. I declare that whatever I have stated herein above is true &correct to the best of my knowledge & belief__________________________________ Name: _____________________________Signature of the witness:Address: ___________________________