Application For Deceased Claim
Application For Deceased Claim
Application For Deceased Claim
From
_________________________________
_______________Branch
_________________________________
___________________
___________________
_________________________________
Dear Sir,
Particulars
A. In case of Nomination:
We submit photocopy of the following documents together with original. Please return the original
4. If the account holder was an ICICI Prudential Life Insurance policy holder, you will need to fill in the
Claimant Statement Form available with the branch in-charge. Please submit this form along with the
following documents at your nearest ICICI Bank branch:
1. Copy of Policy Document / Welcome Kit
2. Copy of Death Certificate issued by Local Authority
3. Claimant / Nominee current address and photo identity proof
Yours faithfully,
Signature
Date : _ _ / _ _/ _ _ _ _
2. Application Form: Deceased Claim ( To be filled at the time of conversion to Estate Account)
From,
________________
________________
To,
The Branch Manager,
ICICI Bank Limited,
________________Branch
Date:_____________
Dear Sir,
DECEASED ACCOUNT - LATE SHRI/SMT ________________ACCOUNT NO(S). _______________________. I/
We __________________________ ___________________________ (relationship with deceased) of Shri/Smt
__________________________(deceased) would like to inform the Bank, of the demise of Shri/Smt.
_______________________ on __________________. He/She holds the above account(s) at _________ branch.
Following are the legal heir (s)/ Nominee for the account of the deceased.
S.No
Name
Father's Name
Address
Date : _ _ / _ _/ _ _ _ _
3. Application Form
( To be used for cases other than Nomination, ERS or Any one or survivior cases )
From ___________________
___________________
___________________
The Branch Manager,
ICICI Bank Limited,
___________________ Branch
Dear Sir,
DECEASED ACCOUNT - LATE SHRI/SMT ________________
ACCOUNT NO(S). ________________
We advise the demise of Shri/Smt. _______________________ on __________________. He/She holds the
above account(s) in your branch. We shall be glad if you please settle the balance amount in the deceased
depositors account(s) to the following :
Shri
________________________
son/daughter
of
______________________
residing
at
_______________________________________________________ Shri _______________________ son/daughter of
_______________________
residing
at
_______________________________________________________
___________________________________________________________________________________________________
_____________________________
2. We submit photocopy of the following documents together with original. Please return the original to us
in due course.
(Tick which is applicable)
3. We note to give other documents required by you like stamped receipt for the amount to be paid, etc., in
due course.
4. If the account holder was an ICICI Prudential Life Insurance policy holder, you will need to fill in the
Claimant Statement Form available with the branch in-charge. Please submit this form along with the
following documents at your nearest ICICI Bank branch:
1. Copy of Policy Document / Welcome Kit
2. Copy of Death Certificate issued by Local Authority
3. Claimant / Nominee current address and photo identity proof
Sincerely,
Signature
Customer Acknowledgement Slip ( to be filled in by Branch Staff)
Date : _ _ / _ _/ _ _ _ _
4. Letter of Disclaimer
(To be obtained when all are signing the claim form and authorising the Bank to pay the amount to
any one of the legal heirs)
The Branch Manager
ICICI Bank Limited
__________________ Branch
Date :-
Dear Sir,
__________________ * Account No.__________
In the name of ____________________________
Balance Rs.______________________________
With reference to the above account (s), I/we the following legal heirs of the late
Shri/Smt._________________________________ (name of the deceased account holder) have to
advise that we have no objection to your paying the balance amount lying in the above account(s)
with
you
by
means
of
a
cheque
favouring
Shri/Smt._______________________________________________. Such delivery of the payment of the
balance in the above account (s) would be completely binding on us and we will not question the
Banks action in so doing, in any proceedings. I/we also undertake to bind ourselves, our heirs
and legal representatives not to revoke the declaration made herein. We also tender a stamped
receipt signed by all of us as a valid discharge.
Sr. No.
1.
2.
3.
4.
5.
____________________________
____________________________
____________________________
(Signature of legal heirs disclaiming the balance)
RECEIPT
Received with thanks from ICICI Bank Limited, _________________ branch, a sum of Rs.
_______________
(Rupees
No.________________
_____________________________
dated
____________
only)
in
by
Bankers
favour
Cheque
of
Yours faithfully,
(Signature)
7. Indemnity format
(To be stamped as an indemnity. Stamp duty to as per applicable stamp Act. )
LETTER OF INDEMNITY WITH RESPECT TO PAYMENT OF BALANCE IN THE DECEASED
CONSTITUENTS ACCOUNT WITHOUT PRODUCTION OF LEGAL REPRESENTATION
To
ICICI Bank Limited
IN CONSIDERATION OF your paying or agreeing to pay to me/us
(1) Insert
________________________________________________________
here
names of
________________________________________________________ the sum
the heirs
of Rupees _____________________________________ standing at the
of the
deceased credit of ______________ account No.__________ with your Bank in the
to whom
name of ______________________________, since deceased, without
payment
is made
production of Letters of Administration or a Succession Certificate to
his/her estate or a certificate from the Controller of Estate Duty to the
effect that estate duty has been paid or will be paid or none is due,
(2) State
here the
names of
the heirs of
the
deceased
(including
those who
signed
Letter of
Authority)
son
of
____________________
and
________________________
son
of
_______________________
_______________________________________________
do
residing at
hereby
for
to
indemnify you and your successors and assigns against all claims,
demands, proceedings, losses, damages, charges and expenses which
may be raised against or incurred by you by reason or in consequence
of your having agreed to pay/or paying to * me/us the said sum as
aforesaid.
1.
2.
2.
(Signature of witnesses)
8. Format of AFFIDAVIT
(To be stamped as an Affidavit)
We
(1)
________________________________
son
of
__________________
and
(2)
________________________________son
of
____________________
residing
at
(1)
___________________________________________________
and
(2)
________________________________________________________ do hereby make oath */solemnly
affirm and say as follows :
2.That we know the deceased and his family since the last _________ years.
3.That at the time of his death the deceased left surviving him the following persons who,
according to the law by which they are governed, are the only legal heirs of the deceased
entitled to succeed to the estate of the deceased on an intestate succession :
Name
Age
Relationship
deceased
with
the
i)
ii)
iii)
iv)
1.That we are not related in any manner whatsoever to the deceased or any of the above
mentioned persons nor have we any claim or interest of whatsoever nature in the
estate of the deceased.
2.That we are informed and we verily believe that the deceased has left certain deposits
*/assets with the ICICI Banking Corporation Limited, ____________________ branch,
which the above mentioned person(s) is/are entitled to claim.
3.That we are making this solemn declaration sincerely and conscientiously believing the
same to be true and with full knowledge that it is on the strength of this declaration that
the ICICI Banking Corporation Limited, _______________ branch, has agreed at our
request, to make payment of the amounts of the deposits */to deliver the assets to the
above mentioned person(s) without insisting on production by him/her/them of a grant
of legal representation to the estate of the deceased from a competent court.
Sworn */solemnly affirmed ]
at this ___________________ ]
day of _______________in the ]
presence of _______________ ]
1.
2.
Before me
Seal
* Judge/Magistrate/Notary
(Delete whichever is inapplicable)
Particulars
A. In case of Single holder and Nomination:
I am holding a nomination in this locker by the name of
Mr./Mrs.
__________________________________________________(nominee name)
son/daughter of ______________________________________ residing at
_____________________________________________________ .
Please settle the claim for the Locker in the name of nominee.
B. In case of joint locker holders and mode of operation as either or
survivor
Request you to delete the name of deceased person and permit
locker operations henceforth in the name all other joint locker
holders with mode of operations as __________________________.
We are enclosing herewith the fresh agreement and application form
in support of the same.
1.
2.
2.
Date :-
Dear Sir,
__________________ * Locker No.__________
In the name of ____________________________
With reference to the above locker (s), I/we the following legal heirs of the late
Mr./Mrs._________________________________ (name of the deceased locker holder) have to advise
that we have no objection to your settling the claim for locker no. ____________________by
allowing access to Mr./Mrs._______________________________________________. Such settlement
would be completely binding on us and we will not question the Banks action in so doing, in any
proceedings. I/we also undertake to bind ourselves, our heirs and legal representatives not to
revoke the declaration made herein.
Sr.No.
1.
2.
3.
4.
5.
____________________________
____________________________
____________________________
(Signature of legal heirs disclaiming the locker contents)
Signed above Letter of Disclaimer before me ________________________ son of
__________________________________
residing
at
_________________
________________________________________________________________
this
day
of
__________________ at _________________________
(Signature of witness)
14. INDEMNITY
(To be stamped as an indemnity. Stamp duty is Rs. 200/- in Maharashtra, in other States relevant
Stamp Act to be referred)
LETTER OF INDEMNITY WITH RESPECT TO LOCKER
CONSTITUENT
To
ICICI Bank Limited
________________ Branch
IN CONSIDERATION OF your having agreed to settle the
claim in respect of the Locker No. ________
Insert
here
names of the
heirs
of
the
deceased
to
whom payment
is made(1)
with your
deceased,
without
production
of
Letters
of
of
__________________
and
of
_________________________,
residing
at
___________________________________________the Sureties
* the persons
named in (1)
do hereby for ourselves and our heirs, legal
representatives, executors and administrators, jointly and
severally UNDERTAKE AND AGREE to indemnify you and
your successors and assigns against all claims, demands,
proceedings, losses, damages, charges and expenses
which may be raised against or incurred by you by reason
or in consequence of your having agreed to settle the
above claim in our favour.
SIGNED AND DELIVERED
1.
2.
2.
(Signature of witnesses)
15. AFFIDAVIT
We
(1)
________________________________
son
of
__________________
and
(2)
________________________________son
of
____________________
residing
at
(1)
___________________________________________________
and
(2)
________________________________________________________ do hereby make oath */solemnly
affirm and say as follows :
1.That Mr./Mrs. ____________________ (name of the deceased) (hereinafter referred to as the
deceased) died intestate on ____________ at __________________________.
2.That we know the deceased and his family since the last _________ years.
3.That at the time of his death the deceased left surviving him the following persons who,
according to the law by which they are governed, are the only legal heirs of the deceased entitled
to succeed to the estate of the deceased on an intestate succession :
Name
Age
Relationship
deceased
with
the
i)
ii)
iii)
iv)
That we are not related in any manner whatsoever to the deceased or any of the above
mentioned persons nor have we any claim or interest of whatsoever nature in the estate of
the deceased.
That we are informed and we verily believe that the deceased has left certain deposits
*/assets with the ICICI Bank Limited, ____________________ branch, which the above
mentioned person(s) is/are entitled to claim.
That we are making this solemn declaration sincerely and conscientiously believing the
same to be true and with full knowledge that it is on the strength of this declaration that the
ICICI Bank Limited, _______________ branch, has agreed at our request, to make payment of
the amounts of the deposits */to deliver the assets to the above mentioned person(s)
without insisting on production by him/her/them of a grant of legal representation to the
estate of the deceased from a competent court.
Sworn */solemnly affirmed ]
at this ___________________ ]
day of _______________in the ]
presence of _______________ ]
1.
2.
Before me
Seal
* Judge/Magistrate/Notary
Description of Articles
____________________________
Name of Branch Official 2
18. LEG [ Para 8C.3, 11D.16 & 13B.16 ] [FEMA 13/2000 dated 03.05.2000]
Application for Remittance of Legacies, Bequests or Inheritances to Beneficiaries Resident Outside
India
Instructions:
1.
Documentation:
2.
Certified copy of the probate together with a copy of the Will annexed
thereto, or letters of administration or succession certificate, as the
case may be, in respect of the Indian assets of the deceased person.
3.
4.
5.
1.
2.
1.
(i)
Name
(i)
(ii)
Nationality
(ii)
(iii)
(iii)
(iv)
(iv)
(v)
(v)
2.
(i)
Name/s
(i)
(i)
Nationality/ies
(ii)
(iii)
3.
(iii)
4.
Country/ies of permanent
residence
Investments
made
repatriation basis
on
3.
non-
(i)
(ii)
4.
I/We hereby declare that the particulars given above and the documents submitted herewith are
true and correct to the best of my/our knowledge and belief. I/We also declare that I/We have not
made any application to any other office of the Reserve Bank of India for the same purpose.
Place : ...............
Date : ...............
....................
(Signature/s of
Applicant)
Authorized Signatory
_______ branch
1.
2.
20. Affidavit from Legal Heirs ( to be taken when the will is not probated)
[TO BE STAMPED AS PER APPLICABLE STAMP DUTY FOR UNDERTAKING + INDEMNITY]
To,
The Branch Manager
ICICI Bank Limited
__________________ Branch
Date :-
Dear Sir/Maam,
__________________ * Account No.__________(Account)
In the name of ____________________________
Balance Rs.______________________________
With reference to the above account (s), I/we the following legal heirs of the late
Shri/Smt._________________________________ (name of the deceased account holder) understand
that ICICI Bank has been approached by ________ (Claimant/s) for settling the proceeds of the
Account on the basis of a will dated _____ that has been left by the deceased and that this will has
not been probated in a court of law. I/we hereby declare that I / we have no objection to ICICI Bank
settling the proceeds lying in the Account on the basis of the will provided by the Claimant/s to
ICICI Bank. I/We hereby confirm that at the time of his/her death the deceased left surviving
him/her the following persons who, according to the law by which they are governed, are the only
legal heirs of the deceased entitled to succeed to the estate of the deceased:
Name
i)
ii)
iii)
iv)
I/we hereby confirm that we are making this solemn declaration sincerely and conscientiously believing the same to be true and with full knowledge that it is on the strength of this declaration that
the ICICI Bank, _______________ branch, has agreed to settle the proceeds lying in the Account on
the basis of the will provided by the Claimant/s.
I/we understand that this no-objection certificate shall be completely binding on us and we will not
question the Banks action in permitting the continuation of the Account in the name of the surviving holders, in any proceedings. I/we also undertake to bind ourselves, our heirs and legal repres-
Further, in consideration of ICICI Bank permitting the settling of the proceeds lying in the Account
on the basis of the will provided by the Claimant based on this no-objection provided by me/us,
I/we hereby undertake to indemnify, defend and hold harmless ICICI Bank, its Affiliates, their respective officers, directors, personnel, representatives and successors, at all times, from and
against any and all direct, indirect, consequential liability / claims / loss (including but not limited
to liabilities, judgments, damages, losses, claims, costs and expenses, including attorneys fees
and expenses) or any other losses that may occur/ accrue to the Bank due to the Bank acting on
the representations made by us in this letter submitted by us or any other instructions in relation
to and / or arising out of this letter. The provision of indemnity as stated herein shall be effective
during the operation of the Account and shall survive the closure of the Account.
____________________________
____________________________
(Signature of all legal heirs named herein)
21. Affidavit from Witnesses of the Will ( In case where the will is not probated)
[TO BE STAMPED AS PER APPLICABLE STAMP DUTY FOR AFFIDAVIT]
AFFIDAVIT TO BE OBTAINED FROM THE ATTESTING WITNESS TO THE WILL
I / We am / are aware that relying on this affidavit the executor / legatee under the said will (name
of the claimant/s)
__________________________________________________________________________________________
_________________________________________________________________ has / have approached
ICICI Bank Limited to make the payment of the balances in the accounts, securities etc. of Shri
____________________________________________ to him.
I / We further state that the contents of this affidavit are true to the best of my / our knowledge and
belief.
22. Indemnity from the Claimant ( In case where the will is not probated)[TO BE STAMPED AS PER
APPLICABLE STAMP DUTY FOR INDEMNITY]
To
ICICI Bank Limited
IN CONSIDERATION OF your paying or agreeing to pay to me/us
(1) Insert
________________________________________________________
here
names of
________________________________________________________ the
claimants
sum of Rupees _____________________________________ standing
to whom
the
at the credit of ______________ account No.__________ with your
payment
Bank in the name of ______________________________, since
is made
deceased, on the basis of a will that has not been probated by a
court of competent jurisdiction,
(2) State
here the
names of
the
claimants
who have
provided
the will.
State here
names of
the
sureties
______________________
son
of
_____________________
residing at _______________________________________________ do
hereby for ourselves and our heirs, legal representatives,
* the
persons
named in
(1)
__________________________
__________________________
__________________________
(heirs of the deceased)
SIGNED AND DELIVERED
by the above named
__________________________
__________________________
__________________________
__________________________
_________________________
(Sureties)
In witness whereof, we have hereunto set our hands at __________________
________________________________________________________________
________________________________________________________________
in the presence of ______________________________________________ on
this day of ________________________________at Place______________
Names and addresses of witnesses :
1.
1.
2.
2.
(Signature of witnesses)
23. NOC from from legal heirs in case of continuation of the same account by other holders
[TO BE STAMPED AS PER APPLICABLE STAMP DUTY FOR UNDERTAKING + IDEMNITY]
No-Objection Certificate
To,
The Branch Manager
ICICI Bank Limited
__________________ Branch
Date :-
Dear Sir/Maam,
__________________ * Account No.__________(Account)
In the name of ____________________________
Balance Rs.______________________________
With reference to the above account (s), I/we the following legal heirs of the late
Shri/Smt._________________________________ (name of the deceased account holder) have to
advise that we have no objection to ICICI Bank permitting the continued operation of the Account
in the name of the surviving Account holders after removal of the name of Shri/Smt ________ from
the list of Account holders. I/We hereby confirm that at the time of his/her death the deceased left
surviving him/her the following persons who, according to the law by which they are governed,
are the only legal heirs of the deceased entitled to succeed to the estate of the deceased:
Name
i)
ii)
iii)
iv)
I/We understand that due to me/us permitting the continuation of the Account and the Account
number it is possible that funds meant for the deceased may end up getting credited to the
Account. In this regard we undertake to not raise any dispute/claim/proceeding against ICICI Bank
with respect to such funds.
I/we hereby confirm that we are making this solemn declaration sincerely and conscientiously
believing the same to be true and with full knowledge that it is on the strength of this declaration
that the ICICI Bank, _______________ branch, has agreed to the request of the surviving Account
holders, to permit the continued operation of the Account in the name of the surviving Account
holder/s after removal of the name of the deceased from the list of Account holders.
I/we understand that this no-objection certificate shall be completely binding on us and we will not
question the Banks action in permitting the continuation of the Account in the name of the
surviving holders, in any proceedings. I/we also undertake to bind ourselves, our heirs and legal
representatives not to revoke the declaration made herein.
Further, in consideration of ICICI Bank permitting the continuation of the Account on the basis of
this no-objection provided by me/us, I/we hereby undertake to indemnify, defend and hold
harmless ICICI Bank, its Affiliates, their respective officers, directors, personnel, representatives
and successors, at all times, from and against any and all direct, indirect, consequential liability /
claims / loss (including but not limited to liabilities, judgments, damages, losses, claims, costs and
expenses, including attorneys fees and expenses) or any other losses that may occur/ accrue to
the Bank due to the Bank acting on the representations made by us in this letter submitted by us
or any other instructions in relation to and / or arising out of this letter. The provision of indemnity
as stated herein shall be effective during the operation of the Account and shall survive the
closure of the Account.
____________________________
____________________________
(Signature of all legal heirs named herein)
___________________________________________________________
*Fill in here the type of account viz. S.B Current etc.
I/ We also undertake to provide ICICI Bank with all other documents as required by ICICI Bank
policy in this regard, for the purpose of final settlement of the Estate Account.
Furthermore with regard to the Estate Account, I/ We hereby confirm, understand and agree that:
(Signature)
Account No.
Outstanding amount
1
2
The Customer hence, had a total outstanding of Rs. _________________ towards the credit facilities
availed by him (Outstanding Due/s) and other dues of Rs. _________________ . Please note that
the bank has in exercise of its right to lien and set-off as agreed to in writing vide Transaction Documents, deducted the Outstanding Due/s of Rs. _______________________ from the total available
balance held by the Customer in his Savings accounts/ current account/ fixed deposit/ recurring
deposit2 towards credit facility (Loans/Credit cards) availed by customer and Rs.
_______________________ towards other dues.
We wish to inform you that after deducting the total Outstanding Due/s and charges of Rs.
___________ , the remaining balance in the afore-mentioned accounts of the customer amounts to
___________ and same have been remitted to you by way of cheque/ DD/ PO/ credited to your
ICICI Bank3 account no. ___________ / transfer to your a/c no on ______________. / so there is no
amount remitted to you.
You may please contact branch_____________ for any clarifications.
Sincerely,
Name
Designation
Annexure-A
Details of account settled
1
2
3
Amount
1
2
I , --------------------------------- (Name of claimant), hereby confirm that the recovery details are duly
informed to me by the branch regarding my respective deceased claim settlement request. I have
understood the same and have no objection/ dispute now as well as in future regarding the
mentioned amount of recovery.
Name of Claimant
Signature of claimant