Annexure 4

Tata AIG General Insurance Co. Ltd.

A-501, Building no-4, IT Infinity Park, Dindoshi, Malad (E), Mumbai, 400097
GROUP PERSONAL ACCIDENT/ AIR ACCIDENT /DISABILITY CLAIM INTIMATION FORM
(SALARY PACKAGE/PENSION A/Cs)
To be submitted for claiming Personal Accident Insurance (PAI) (death only) /Air Accident Insurance
cover (AAI) (death only) within 90 days after date of death of Salary Package Account holder of SBI
(Intimation may be advised through Email, Post, Telephone/ Fax) Issuance of this format for intimation
of a claim is not to be taken as an admission of liability. Death/Disability due to accident only is
covered under the Policy and account should be under Salary Package as on date of
accident/death/disability)
#Do not leave any fields Blank, mark NA where not applicable.

Policy No. Address:

(A/c State Bank of India) Tata AIG General Insurance Co. Ltd
A-501, Building no-4, IT Infinity Park,
Dindoshi, Malad (E)
Policy Period 04 .01.2022 to 03.01.2023 Mumbai,400097
Phone/Fax No.022-66930000/66699718
Email Id: [email protected]
[email protected]

1 Name of Salary/Pension Account holder

Address in full
2

a) Date of Accident
b) Time of Accident
3 c) Place of Accident

d) Details of Accident

e) Date of Death

4 Salary Package/Pension Account No.

Xpress Credit (PL) Outstanding (if any), Ac
for DSP/CAPSP/ICGSP (Death in action No
5
against Anti National Activities, Terrorist,
O/s
Naxalite foreign enemy only
Type of Salary Package/Pension Account (Tick CSP/DSP/CAPSP/ICGSP/SGSP/CGSP/PSP/RSP/SUSP/
6
the appropriate one) Pensioner (DSP/CAPSP/ICGSP)
Variant of Salary Package A/c (tick the
7
appropriate box) Silver Gold Diamond Platinum

1
 Army / Air Force / Navy / Indian Coast Guard/ Assam
Rifle / Rashtriya Rifle / BRO (GREF) / BSF / CRPF / CISF /
ITBP / SSB / NSG/RPF/ NDRF/SPG
Unit Address:
8 Name of Organization for DSP/CAPSP/ICGSP

Contact Detail
Landline:
Mobile No:
Name of Employer:
Name of the organization for others i.e.
9
PSP/CGSP/SGSP/RSP/SUSP/CSP Department Name:

Personnel/Force/Batch No./ Employee

10
ID number
Branch Name:
Details of SBI Branch where Salary Account Branch Code:
11
was maintained Place:
State:
Name of Nominee/Joint Account holder in the
12
salary package account [as per Bank’s record]
13 Relationship of Nominee with Account Holder

14 Address of the Nominee

15 E Mail ID of Nominee (if available)

Contact Number of Nominee
16
(if available)
[#Corporate Salary Package (CSP), Defence Salary Package (DSP), Central Armed Police Salary Package (CAPSP), Indian
Coast Guard Salary Package (ICGSP), State Government Salary Package (SGSP), Central Government Salary Package
(CGSP), Police Salary Package (PSP) and Railway Salary Package (RSP), Start-up Salary Package (SUSP)]
(@ Please tick on the appropriate organization)

Above information are true to the best of my / our knowledge and belief.

Signature of person Intimating Claim ……………………………………………………………………………….

Full Name of person Intimating Claim ……………………………………………………………………………….

Relationship with Deceased Account Holder ………………………………………………………………………..

Contact details of Person Intimating Claim

Landline No ………………………………………….
Mobile No ………………………………………….
Email ID ……………………………………….

2
 Annexure- 5

Tata AIG General Insurance Co. Ltd.

A-501, Building no-4, IT Infinity Park, Dindoshi, Malad (E), Mumbai, 400097
GROUP PERSONAL ACCIDENT/ AIR ACCIDENT CLAIM FORM
(TO BE FILLED BY NOMINEE/ CLAIMANT/ LEGAL HEIR)

Submission of this format for claim is not to be taken as an admission of liability.

Policy No. Address:

(State Bank of India) Tata AIG General Insurance Co. Ltd
A-501, Building no-4, IT Infinity Park,
Dindoshi, Malad (E)
Policy Period 4.01.2022 to 03.01.2023 Mumbai,400097
Phone/Fax No.022-66930000/66699718
Email Id: [email protected]
[email protected]

1 Name of Salary/Pension Account holder

2 Address of Claimant

3 Date of Accident
Date of Death of Salary/Pension Account
4
Holder
Cause of Death
5
6 Salary/Pension Package Account No.
Xpress Credit (PL) Outstanding (if any),
7 Ac No: O/s as on date:
for DSP/CAPSP/ICGSP only
8 Name of the organization
Name of Nominee/Joint Account holder
9
in the salary/pension package account
Mobile Number of Nominee/ Joint
10
account holder
Contact Number of other close
11
person/relative
Branch Name:
Branch Details where Salary/Pension Branch Code:
12
Account is maintained Place:
State:
PAI: Rs.

Claim Amount (eligibility as per he AAI: Rs.

13
variant/Package)
Add on Covers: Rs.

3
 Please ensure to enclose below mentioned documents:

DOCUMENTS TO BE SUBMITTED ALONG WITH ANNEXURE 5 (Claim Form)

Sl Enclosed Enclosed
No. Documents (Yes / No Documents Yes / No
Viscera Report / Chemical Analysis
I Report in case where postmortem
Annexure 4: Claim Intimation
report shows the cause of death due
Form VIII
to poisoning or alcohol or confirm
after Viscera/Chemical Analysis
Report
Annexure 6:
Aadhar Card of Nominee/Joint
Duly stamped and signed
XI Account holder /Claimant in the
II Certificate by SBI Branch
salary package account
Manager on Bank Letter head.
Annexure 7:
PAN card copy of the Nominee/Joint
Bank details/ NEFT Form of
Account holder/ Claimant in the
Nominee/Joint Account X
III salary package account. if not
/Claimant holder in the salary
available, then form 60
package account
Attested copy of the first page of the
IV Bank Passbook or cancelled Cheque
containing the Name of Account
Attested Copy of Death
XII Holder (claimant), IFSC Code of the
Certificate
Bank, Bank Account Number of
Nominee/Joint Account holder/
Claimant
Other suitable document to prove
V Attested Copy of Postmortem legal heirship in case claimant is not
XII
Report a nominee / joint account holder as
per Bank’s record
In case of multiple heirs, (consent
Attested Copy of FIR Report XIII
VI from all the legal heirs)
Defence Authority report in Certified Copy of Final Police
VII case FIR is not available (For XIV Investigation Report in case of train
Armed forces) accident/drowning/murder

I hereby declare that the foregoing statements made by me are true in all respects, that I have not
attempted to conceal from the Company anything with which it ought to be made acquainted and that
if I have made or in any further declaration the Company may require shall make any false or fraudulent
statement or untrue averment whatever, the Claim shall be void and my right to compensation forfeited.
I am willing if required, to make and provide to the Company a statutory Declaration of the whole of the
foregoing statement or of any other statement made in connection with this claim.
Signature of Nominee/Joint Account Holder/Claimant
Name

Date
4
 Annexure 6
To be submitted on Bank’s letter head

This is to certify that Shri/Smt/Ms. who expired on due to accident

(as per the documents submitted by the nominee/ claimant), is a holder of Salary Package Account:
1 Name of the Salary Package Account holder :
2 Address in full (as per Bank records) :
3 Date of Accidental Death (as per death certificate) :
4 Details of SBI Branch where the Salary Package : Br. Name:
Account is maintained Br. Code:
: State:
Module:
Circle:
5 Salary Package Account Number :
Xpress Credit (PL) Outstanding (if any), for Ac No.
6 :
DSP/CAPSP/ICGSP only O/s as on Date:
7 Name of Salary Package account :
DSP/CAPSP/ICGSP/PSP/CSP/SGSP/CGSP/RSP/SUSP
: Silver/ Gold Diamond
8 Salary Package Account Variant:
Platinum
9 Date of last Salary Credit (Prior to Accident) :
10 Claim amount under PAI/ Air : PAI: AAI:
11 Name of the Joint account holder of Salary Account (if
available)
12 Address/Contact No of Joint Account holder
13 Is nomination available in the Account of the
deceased (Yes/No to be mentioned)
14 Name of nominee(s), if available :
Contact No./ Address of Nominee :
15 Nominee A/c details (Ac should be in SBI only) :

Details of Bank account and nominee have been furnished only after verifying the same
in CBS. The undersigned will not be held responsible for the genuineness/authenticity of documents like
FIR, Death Certificate, Postmortem report, etc. submitted by the claimant to the Insurance Company. It shall
be the responsibility of the Insurance Company to ascertain their authenticity. All further correspondence
should be made directly between the claimant and the Insurance Company. The claim settlement will be
entirely the responsibility of Insurance Company. All settlements/disputes will be between the claimant and
the Insurance Company, and the Bank will not be a party to such disputes.

For State Bank of India

Branch Name
Branch Code Signature of Branch Manager
Date:
Name of the Signing Officer:

5
 Annexure 7

NEFT FORM FOR PERSONAL ACCIDENT INSURANCE

(To be submitted by the Nominee/Claimant/Legal heir only)

Tata AIG General Insurance Co. Ltd.

A-501, Building no-4, IT Infinity Park, Dindoshi, Malad (E), Mumbai, 400097
[email protected]
(Policy No. ……………….)
Sir,

I/We furnish below details of my/our SBI account to be used for effecting payments due to us by
NEFT/RTGS

SBI Account Details for NEFT/RTGS

Name of the Claimant (Account Holder)
Bank Name State Bank of India
Bank Branch Name
Bank Branch Address
MICR Code
Full Bank Account No. (for NEFT)
IFSC Code

Please attach a copy of a cancelled cheque leaf or Photocopy of the first page of the Bank
Passbook containing the name of account holder, Bank account number, and IFSC code.
Please verify the details with your bank before submitting.

I/We hereby declare that the particulars given above are correct and express my/our
willingness to receive credit of claim proceeds through the mode indicated above.
Notwithstanding my/our choice of mode, Tata AIG General Insurance Co. Ltd. reserves the
right to issue a cheque/credit the account in the mode that may seem fit. I/We would not
hold Tata AIG General Insurance Co. Ltd. responsible if the transaction if delayed or not
effected at all or credited to an incorrect account for the reasons of incomplete/incorrect
information.

I authorize State Bank of India to recover / adjust any Loan / dues outstanding in the name
of the life assured/deceased before allowing release of funds form my account in which
insurance claim due is paid.

Name: (………………………………………)

Place:
Signature of the Applicant (Claimant) Date: …../…./……..