THE  NEW  INDIA  ASSURANCE  COMPANY  LIMITED
DIVISIONAL  OFFICE - 712500
    Allied Mount Casa Blanca Building, 2nd Floor, 260 Anna Salai, (Old No. 702),CHENNAI-600 006.
                  Phone  044-23456824/26/27   Fax : 044-23456825 Email: nia25@vsnl.com

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY
AND SUBJECT TO VALIDITY OF THE CITIBANK CARD AS ON THE DATE OF ACCIDENT.

PERSONAL ACCIDENT INSURANCE CLAIM FORM
(Claim form for Accidental Death only)

INSTRUCTIONS FOR FILLING UP THIS CLAIM FORM

1) Preliminary notice of claim should be sent to the Company within 30 days from the date of death of the insured card member.

2) The completed claim form duly signed by the claimant, who shall necessarily be one of the legal heirs, together with the following documents should be submitted to the Company at the earliest and in any case not later than 6 months from the date of death of the card member or within such further time as may be granted by the Company in this regard in writing.

3) While sending xerox copies to the Company it may be ensured that they are of readable quality. This is very important, especially in cases where such  documents are in any language other than English, to facilitate easy and quick translation into English and faster claims processing. English translation can be arranged at our end only  "for the documents which are in HINDI".  Copies of any document translated into English from any other language should be duly attested by the official language translator approved by the Govt. and duly notarized. 

4) While sending xerox copies to the Company it may be ensured that they are duly verified and attested by a Class I officer of The New India Assurance Company Limited  on all pages with Signature, Name, Designation and Office Address of the Official.

5) Checklist for documents to be submitted along with the claim form :

a) Death Certificate (Original or xerox copy duly notarised or duly attested by an Officer of the Company)

  YES  /  NO

b) FIR of Police Authorities (Original or xerox copy duly notarised or duly attested by an Officer of the Company)

  YES  /  NO

c) Post Mortem Report along with Chemical Analysis Report (Original or xerox copy duly notarised or duly attested by an Officer of the Company)

  YES  /  NO

d)  Police Inquest Report or Panchanama /Accident Reports (Original or xerox copy duly notarised or duly attested by an Officer of NIA)

  YES  /  NO

e) Admission cum Death Summary from the Hospital in case of Hospitalisation following accident.

  YES  /  NO


6) Upon approval of the claim, if nomination is not available,  an approval letter will be sent by the Company calling for the submission of the documents as per check list given below to evidence the legal entitlement of the claimant to the insurance compensation payable  under this policy.
 

a)  Legal Heirship Certificate issued by Competent Revenue Authority by Tashildar or District Collector or District/Divisional/Sub-Divisional Magistrate  and Indemnity Bond. YES  /  NO
b) If Legal Heir Certificate is not available, then Succession Certificate issued by Court YES  /  NO
c) If Succession Certificate issued by Court is not available, then following set of documents should be produced by the claimant formats of which will be sent to the claimant on request.: YES  /  NO

i)

 Application form for dispensing with legal evidence of title.  

ii)

 Affidavit from the claimant(s) that he/she/they is/are the Legal Heir(s) of the deceased, duly notarized and in a non-judicial stamp paper of prescribed denomination.  

iii

 An Affidavit from other near relatives(other than minors) of the deceased that they have no objection if the claim amount is paid to the claimant(s), duly notarized and in a non-judicial stamp paper of prescribed denomination.  

iv

 Letter from Surety, who is a person of reasonable standing, informing the Company that he/she will execute Indemnity Bond alongwith proof for his/her financial soundness.  

v

 Indemnity Bond executed by Surety.  
vi Indemnity Bond to be executed by all Legal Heir (s).  
vii  Newspaper notification about the claim settlement in the prescribed format.  
viii Special Discharge Voucher duly attested by Magistrate / Gazetted Officers / Notary Public.  

CLAIM FORM

Policy No.   71250034/                                                                                     Claim No.

(Please adhere to the stipulation regarding documentation detailed in the instructions given above.)

(To be completed by the first legal heir of the deceased insured person)

1.  Details of deceased insured person :

   . a) Name 

     b) Address (where he/she was residing)

     c)  Profession/occupation 

     d)  Age & date of birth

     e)  Marital status 

     f)   Name of Father/Husband 

     g)  Proof of identity (to attach notarized xerox copy of any one of the following)          

1)  Passport No.  
2)  Voter's Identity Card No.  
3)  Ration Card No.  
4)  Driving Licence No.  

     h)   CITI BANK CARD No.  (To attach xerox copy of latest card statement)           

Card Number

Date of Expiry

   
   
   
   

      i)  Details of Good Health Personal Accident Policy Certificate if any, covering the deceased.

 Certificate Number   Policy Period
   


2   Details of accident

      a) Date 

      b) Time 

      c) Place

      d) Brief details about nature and Cause of Accident 

      e) Date of death (attach death certificate in original)

      f)  Place of death

      g) Cause of death

      h)  Whether the accident has been reported to
           police and if so to which police station ?
          (attach copy of FIR of police duly attested
            by concerned Police Officer)

3   Name of the hospital where the Post Mortem
      was conducted (attach Post Mortem Report
      copy duly attested by the concerned authority)

4.  What other documentary proof is produced to evidence
     "accidental" death of the Insured card member ?

5.  Name & address of hospital where the deceased was admitted/
     treated  immediately after the accident.
     (Attach original record of the hospital including Admission/Discharge/
     Death summary)

 

6. CERTIFICATE TO BE FILLED UP AND SIGNED BY AN EYE WITNESS TO THE ACCIDENT

I hereby certify that I was present when the Accident occured to Mr/Ms.                                                              

on the                              day of                                              year                            in the manner stated

overleaf.  It was caused by                                                                                           which was not wilfil act

and that *"he/she was"  / "he/she was not " under the influence of intoxicating liquor at the time of accident. (* Strike

out which is not applicable)


SIGNATURE & NAME OF EYE WITNESS                         ADDRESS


OCCUPATION

DATE

If eye witness certificate is not obtained, reasons thereof:

7. Details of any other insurance policy, granting compensation for accident, covering the deceased insured person

Sl.No.  Insurance Policy No.  Policy Period  Sum Insured  Insurance Co. Name and
 Office Address
1        
2        
3        
4        
5        

8.  Name of Legal Heir(s) of the deceased insured person

Sl.No. Name Relationship Age
       
       
       
       


I hereby declare that the foregoing statement are made by myself and are true in all respect and that I have
not attempted to conceal from the Company anything which is ought to be disclosed and that I shall make any declaration the company may require, and that should I make any false or fraudulent statement or any suppression concealment or untrue averment whatsoever, the policy shall be void and my right to compensation forfeited and I am willing, if required to make a Statutory Declaration before a Justice of Peace of the whole of the foregoing statement or any other statement I may make in connection with this claim.

 

Witness :  Name                                                                                                                                   
       
                Signature                                                                          Signature of First Legal Heir & Date

                Date                                                                                 Name                                                     

                Full address                                                                      Relationship

                                                                                                        Full Address