STATE LIFE
Claim Form A
Insurance Corporation of Pakistan (Form –IVA)
CLAIMANT’S STATEMENT
Policy No: ___________________________Name of the Life _______________________________
Instructions for completion of this form:
This form is to be completed by the person legally entitled to claim policy moneys i.e. Nominee, Guardian, Trustee, Assignee OR
holder of Succession Certificate.
In case if there are more than one claimants, each will be required to submit a separate form.
Please provide complete information. Incomplete and blank forms and columns left blank will not be entertained.
Please fill in the form with clear and legible handwriting and avoid cutting and overwriting.
1. Please provide following information about yourself:
Name: __________________________________________ CNIC No: ________________________________
Age or date of Birth: _________________________ Occupation: ____________________________________
Address: ___________________________________________________________________________________
__________________________________________________________________________________________
Cell/Phone No: ________________ Fax No: _________________ Email Address: ________________________
Relationship with the life Insured: ___________________________________________________________
2. Please tick the box below describing nature of your title under which you claim the policy money:
Nominee Guardian Trustee Assignee Successor
3. Please provide details about the deceased life insured:
Name: _________________________________________ CNIC No: __________________________________
Last Occupation: ___________________________________________________________________________
Last Address: ______________________________________________________________________________
Date of Death: ______________________ Place of Death: __________________________________________
Immediate cause of death: __________________________________________ Age at death: _____________
Duration of last illness: ______________________________________________________________________
4. Please state particulars of other life or health insurance policies of the life Insured:
Policy No(s): _______________________________________________________________________________
Date(s) of issue: ____________________________________________________________________________
Issuing Office(s): ____________________________________________________________________________
5. (a) Please state as to when did the deceased life insured first complain of being not in usual good
health_______________ (b) Nature of illness then complained of: __________________________
6. Please provide details of medical attendant(s) consulted during last illness of the deceased:
a) Doctor’s / Hospital/Name a) Doctor’s / Hospital/Name
b) Address b) Address
c) Dates of consultations c) Dates of consultations
d) Complaints d) Complaints
(Please attach the prescriptions/Hospital certificate/Lab reports/postmortem/FIR and /or any other document.
7. Please provide following details about the illness of life insured pertaining to the last three years:
Doctor’s Name and Address Date of First Consultation Nature of Complain
8. Please list out below the particulars of family members of the deceased has left:
Names Ages Relationship with the deceased
9. Please state is there any will? If yes, then please attach a copy of the same.
Declaration: I _______________________________________________________ do hereby declare that the information
provided by me in this form is true in each and every respect and that I have not withheld any material information.
I being _________________________________ of the deceased, hereby authorize any hospital, physician or any other
person who had attended the life insured to give State Life all the knowledge and information which was thereby acquired
including the history obtained and diagnosis made.
Signed at _____________________________ this _________________ day of ___________________ 20 ____
___________________
(Signature/LTI/RTI of Claimant)
Attestation:
The statement below must be signed by a Grade-17 and above, Nazim, Naib Nazim, Chief Executive Officer of Municipality
Justice of Peace, Magistrate, collector or Judge of the place or district where the death took place or an officer of State Life
(not below the rank of Area Manager on the administrative side if he or she knows the claimant.
I certify that the claimant has signed it before me and I have verified his or her CNIC
Signature with seal: __________________________________________ Date: _________________________________
Name: ____________________________________________________________________________________________
Address: __________________________________________________________________________________________
Phone No: _____________________ Fax No: ________________________ CNIC No: ____________________________
