Group Gratuity Claim Form - ICICI Prudential Life Insurance

Group Gratuity Scheme - Claim Intimation FormPolicy Number:(dd / mm / yyyy)Name of the Trust:Type of Claim: Death / Retirement / ResignationName of the member :Member ID :Last nameDate of Birth :Normal Retirement Date :Last Drawn Salary (Rs.) :Date of joiningLast Working DayNature of DisabilityCompleted years & month of service : years monthsAdditional Information in case of death claim:Date and time of death :Place of death (E.g. Address of hospital, City) :HrsMinCause of claim :(Please specify exact cause of death)Details of leave taken one year prior to commencement of member's cover:From (Date) To (Date) Reasons for leaveNature of illness (in caseof medical leave)If leave has been taken on medical grounds copies of leave applications and medical certificates produced by the Member mustbe attached herewith.Please provide the following details in case the death claim payout cheque has to be issued in favor of the beneficiary:Full Name of the Beneficiary :Relationship with deceased member :Last nameDetails of the Appointee (who should be a major) where beneficiary is a minorFull Name of the Appointee :Relationship of appointee with beneficiary :Last nameAcceptance & Sign of AppointeeDocuments required for processing death claim :Cause of claimNon Accidental DeathAccidental Death / Murder /SuicideDocument required Copy of Death Certificate issued by local authority Copy of Post Mortem Report Copy of FIR & Copy of Death Certificate issued by local authority1

Details of Withdrawal of unitsPlanWithdrawal (%) basisGroup Short Term Debt FundGroup Debt FundGroup Balanced FundGroup Growth FundGroup Capital Guarantee Short Term Debt FundPayment Details:Claim amount to be paid (Rs.) :Specify Name of Payee :We are aware that ICICI Prudential has a right to call for further information / documentsAdvance Discharge Voucher:We ………………………….......................................... (name of the Trust) understand and agree that ICICI PrudentialLife Insurance Company shall be discharged of all liabilities in relation to the above claim upon the payment of theClaim moneys in case of acceptance of the claim by the Company.Please affixRe. 1/-revenuestamp & signacross thestampStamp of the Trust :Signature of the authorized signatoryName of the signatory:Place : Date :Instructions :The units to be withdrawn for the claim payment will be computed by using the NAV on the day of receipt ofclaim intimation or last requirement whichever is later.The claim cheque would be dispatched to the last address recorded by usICICI Prudential Life Insurance Company shall be discharged of all liabilities in relation to the above claim uponreceipt of claim amount by the payee mentioned above.Group Service Desk 022- 66698199 grouplife@iciciprulife.comICICI Prudential Life Insurance Company Ltd., Group Service Desk, 4th Floor, Stanrose House, Appasaheb Marathe Marg, Prabhadevi, Mumbai - 25.2