Dread disease / critical illness benefit form - Max Life Insurance

Max Life Insurance Company Ltd.90 A, Sector-18, Udyog Vihar, Gurgaon-122015, HaryanaPhone Number- 0124-4219090- Extn- 9699, Toll Free- 18002005577Email- claims.support@maxlifeinsurance.comApplication Form For Dread Disease / Critical Illness Benefit Claim - (Form-AA)Notes/Guidelines• This form is to be filled in by the person legally entitled for the policy money. All the answers must be clear &unambiguous.• The benefit is payable subject to policy being in force on the date of event and also subject to fulfillment of allconditions/definitions as stated in the policy.• Submission of this form should not be construed as acceptance of claim.• Speedy and complete submission of documents would enable the company to expedite the claim processing.Policy No:I. Information about the Life Assured1 a) Name of the Life Assured………………………………………………………c) Age at Claim……………………………………….2. Bank Details- (Mandatory)Contact No of Life Assured:b) Complete Mailing Address………………………………………………………………………………………………………………………………Name as per Bank Records……………………………………………………………………………………….Bank Name and Branch :…………………………………Bank Account No: ………………………………MICR Code…………………………………………………IFS Code……………………………………………(It is advisable to submit cancelled cheque for cross verification of bank details)II. Information about the Dread Disease / Critical Illness1.Claim submitted for (please tick any one of the below)-Heart Attack Cancer Stroke ComaMultiple Sclerosis Paralysis Kidney Failure Major Organ TransplantCoronary Artery Bypass Graft Surgery (CABGS)Heart Valve Replacement or Repair2. Exact Diagnosis……………………………………………………………………………………………………3. Date of Diagnosis / Surgery………………………………………………………………………………………4. Date of First Consultation…………………………………………………………………………………………III. Information about the Doctor(s) consulted and Hospitals from where treatment was takenS.No Name of Doctor/ Hospital Contact Number Date of FirstConsultationTreatment takenb) Name of Family Doctor……………………………………………….Contact Number…………………Ver 1.2 June 05, 2012

Max Life Insurance Company Ltd.90 A, Sector-18, Udyog Vihar, Gurgaon-122015, HaryanaPhone Number- 0124-4219090- Extn- 9699, Toll Free- 18002005577Email- claims.support@maxlifeinsurance.comIV. Declaration and AuthorizationI………………………………………………… do hereby declare that the statements made herein above are true and complete in all respects.Notwithstanding any law, custom or convention, or usage, for the time being in force prohibiting any physician or hospital from divulging anyknowledge or information, acquired by him / them in attending upon of examining a person on the ground of secrecy. I hereby authorize anydoctor, physician or hospital who has attended upon or examined or treated me for any ailment or illness to divulge any knowledge orinformation regarding my state of health which he / they may have acquired whether before or after the policy was issued by the Company, tothe MAX LIFE INSURANCE COMPANY LTD., any of its offices, or Court of Law.Signed at……………… (Place) on this…………..Day of. ………Month…………Year.Signature of Life Assured………………………………..Signature of Witness- MandatorySignature :Name :Address :……………………………………………………………………………………………………………………………………………………………………………Phone No (With Std Code) ……………………….The form must be witnessed by any one of the following: (1) AnAgent (2) Sales Manager / Branch Manager of the company (3)Block Development officer (4) A Bank Manager of a Nationalizedbank with Rubber Stamp (5) An officer of the Company not belowthe rank of Manager (6) A Gazetted Officer (7) A Head Master /Principal of a Govt. School (8) A Magistrate.Declaration in case of an illiterate Claimant where his/her left thumbs impression should be made by a person of standing unconnected with thecompany and whose identity can be easily established.“ I hereby certify that the contents of above form are explained by me in the Language understood by the Claimant and that he/she has affixedhis/her thumb impression to this form after fully understanding the contents thereof.”(Full Signature of the Witness)Name of Agent Advisor / CRO:…………………………Name of Sales Manager:………………………………….Agent / CRO Code: …………………………SM Code:…………………………………………V. Please submit the following documents along with this Form1. Attending Physician Statement –Form-DD2. All Consultation notes/Prescriptions in connection with the Dread Disease/Critical Illness.3. Admission & History Sheet and Discharge Summary from the treating Hospital(s).4. All Test Reports such as Biopsy report, ECGs, Cardiac Enzyme reports, blood tests, neurological tests, surgery notes.NOTICE: Any person who knowingly files a claim containing false or misleading information, or who conceals information with intent to defraudor mislead the Company or other person, may be guilty of felony or subject to other criminal and/or civil penalties as the case may be under theapplicable law(s) of the State.Ver 1.2 June 05, 2012

Max Life Insurance Company Ltd.90 A, Sector-18, Udyog Vihar, Gurgaon-122015, HaryanaPhone Number- 0124-4219090- Extn- 9699, Toll Free- 18002005577Email- claims.support@maxlifeinsurance.comElectronic Funds Transfer- Mandate formI Mr./Ms. ______________________________________, son/daughter/wife of__________________ resident of _____________________________________________________________________ am a claimant/Policy Holder under the PolicyNumber__________________________. I do hereby request Max Life Insurance CompanyLimited electronically transfer the claim payment under the above mentioned policy number in tomy bank account as per detail given below.Account Holder Name: ______________________________________________Bank name: ___________________________________________________________Type of Bank Account: ______________________________________________Bank Account Number: ______________________________________________Branch Address:____________________________________________________________________________________________________________________MICR code:______________________________________________IFSC code (Indian Financial Security code):_________________________________Declaration–I agree to save and hold Max Life Insurance Company Limited harmless and indemnified against any and/or all losses, claims,liabilities, legal proceedings (including attorney fees’), expenses, or damages suffered by or taken against Max Life InsuranceCompany Limited arising on account of any error or misrepresentation in the information furnished in this EFT mandate by me.Date:Account Holder / Claimant Signatures: ____________________________________Bank Verification -I, the undersigned authorized person, on behalf of the above mentioned bank, , confirm that the bank account details of the individualas mentioned in this EFT Mandate form are correct and are hereby verifiedName of Bank:_________________________________________________________________Bank verification Stamp with branch address and Signature of the Banker__________________Name of the Signing authority_____________________________________________________Please attach a copy of cancelled Cheque or copy of bank account passbook bearing the above mentionedaccount number along with this form.Ver 1.2 June 05, 2012