Annexure 4

UNITED INDIA INSURANCE CO. LTD

DO- XI, Maker Bhavan No.-01, 1st Floor, Sir V. T. Marg, Mumbai -400 020

GROUP PERSONAL ACCIDENT/ AIR ACCIDENT CLAIM INTIMATION FORM (SALARY PACKAGE 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 due to accident only is covered
under the Policy and account should be under Salary Package as on date of
accident/death)

Policy No. 1203004220P113804906 Address: DO – XI, Maker Bhavan No.1,1st floor,

(A/c State Bank of India) Sir V.T. Marg, Mumbai – 400 020.
04 .01.2021 to Phone No.022- 22624525/22624818
Policy Period 03.01.2022 Fax No. : 022-22624579
Email Id:
120300@uiic.co.in/ sbigpaclaims@gmail.com

1 Name of Salary 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 Account No.
Type of Salary Package Account (cross the
5 # CSP/DSP/CAPSP/ICGSP/SGSP/CGSP/PSP/RSP/SUSP
appropriate one)
Variant of Salary Package A/c (tick the
6
appropriate box) Silver Gold Diamond Platinum
Army / Air Force / Navy / Indian Coast Guard/ Assam
Rifle / Rashtriya Rifle / BRO (GREF) / BSF / CRPF / CISF /
ITBP / SSB / NSG/RPF/ NDRF/SPG
Unit Address:
7 Name of Organization for DSP/CAPSP/ICGSP

Contact Detail
Landline:

1
 Mobile No:
Name of Employer:
Name of the organization for others i.e.
8
PSP/CGSP/SGSP/RSP/SUSP/CSP Department Name:

Personnel/Force/Batch No./ Employee

9
ID number
Branch Name:
Details of SBI Branch where Salary Account Branch Code:
10
was maintained Place:
State:
Name of Nominee/Joint Account holder in the
11
salary package account [as per Bank’s record]
12 Relationship of Nominee with Account Holder

13 Address of the Nominee

14 E Mail ID of Nominee (if available)

Contact Number of Nominee
15
(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

UNITED INDIA INSURANCE CO. LTD.

DO- XI, Maker Bhavan No.-01, 1st Floor, Sir V. T. Marg, Mumbai -400 020
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. 1203004220P113804906 Address: DO – XI, Maker Bhavan No.1,1st floor,

(State Bank of India) Sir V.T. Marg, Mumbai – 400 020.
Phone No.022- 22624525/22624818
Fax No.: 022-22624579
Policy Period 4.01.2021 to 03.01.2022 Email Id:
120300@uiic.co.in/ sbigpaclaims@gmail.com

1 Name of Salary Account holder

2 Address of Claimant

3 Cause of Death
Date of Death of Salary Account Holder
4
5 Salary Package Account No.
6 Name of the organization
Name of Nominee/Joint Account holder
7
in the salary package account
Mobile Number of Nominee/ Joint
8
account holder
Contact Number of other close
9
person/relative
Branch Name:
Details of SBI Branch where Salary Branch Code:
10
Account is maintained Place:
State:
PAI: Rs.

Claim Amount (eligibility as per he AAI: Rs.

11
variant/Package)
Add on Covers: Rs.

Please ensure to enclose below mentioned documents:

3
 DOCUMENTS TO BE SUBMITTED ALONG WITH ANNEXURE 5 (Claim Form)

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

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

Policy No.: 1203004220P113804906 Policy Period 04.01.2021 to 03.01.2022

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 :
6 Name of Salary Package account :
DSP/CAPSP/ICGSP/PSP/CSP/SGSP/CGSP/RSP/SUSP
: Silver/ Gold Diamond
7 Salary Package Account Variant:
Platinum
8 Claim amount under PAI/ Air : PAI: AAI:
9 Is nomination available in the Account of the
deceased (Yes/No to be mentioned)
10 Name of nominees, if available :
Address of Nominee :

Contact No. :
11 Nominee A/c details if available :
12 Full name of Joint Account Holder(s) of the above- :
mentioned Salary Package Account (for Joint Accounts
only) and address
Contact No. of Joint account holder/s :

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 (SS No. )
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)

UNITED INDIA INSURANCE CO. LTD.

DO- XI, Maker Bhavan No-01, 1st Floor, Sir V. T. Marg, Mumbai -400 020 Email Id:
vtsangtani@uiic.co.in
(Policy No. 1203004220P113804906)
Sir,

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

Bank Account Details for NEFT/RTGS

Name of the Claimant (Account Holder)
Bank Name
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
Pass Book 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, United India 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
United Insurance Co. Ltd. responsible if the transaction is delayed or not effected at all or
credited to an incorrect account for the reasons of incomplete/incorrect information.

Signature of the Applicant (Claimant)

Name: Place:
Date:

6
 (On Bank’s Letter Head)

Annexure 8

UNITED INDIA INSURANCE CO. LTD.

DO- XI, Maker Bhavan No.-01, 1st Floor, Sir V. T. Marg, Mumbai -400 020 Email Id:
vtsangtani@uiic.co.in

No. Dated:

Dear Sir/ Madam

CLAIM UNDER PERSONAL ACCIDENT INSURANCE (DEATH)/ AIR ACCIDENT (DEATH) COVER FOR
SALARY PACKAGE ACCOUNT No:___________________________________
POLICY NO: 1203004220P113804906
VALID FROM 04/01/2021 TO 03/01/2022
SALARY ACCOUNT HOLDER: _________________________________________
CLAIMANT: SHRI/SMT/Ms______________________________________________

We forward herewith application for claim under Personal Accident Insurance (Death)/ Air Accident
Insurance received from Shri/Smt/Ms.………………………….. Son/Spouse of Shri/Smt/Ms.
………………………………., a Salary Package account holder with our branch under ……………. Salary
Package, along with the following enclosures:

a) Copy of claim intimation form. (Annexure 4)

b) claim form (Annexure 5)
c) Certificate from the Bank along with the name of the nominee/ joint account holder, duly
certified by the Bank officer with full address. (Annexure 6)
d) NEFT Form of the claimant, containing original cancelled cheque of the Bank account on the
name of the claimant/ Photocopy of the first page of the Bank Pass Book containing the name
of account holder, Bank account number, IFSC code. (Annexure 7)
e) Attested Legible Copy of Death Certificate.
f) Attested Legible Copy of Police report and FIR with incident report. (For armed forces, Defence
authority report in case FIR is not available)
g) Attested Legible Copy of Postmortem Report
h) Pan Card copy /Form 60 of the Nominee/Legal heir
i) Aadhaar Card copy of Nominee/Legal heir

(Note: for Air Accident (Death) Insurance claim: Certified copy of Bank statement of Salary Package
account indicating purchase of Air ticket/ payment to travel agent for purchase of Air ticket by debit
to Salary Account using SBI Debit Card/ Internet Banking).

The application and above documents are being forwarded to you, without any responsibility of the
Bank or its officers regarding their genuineness/ authenticity except item (f) above and it shall be
the responsibility of the Insurance company to ascertain the authenticity of the relevant documents.

7
For any clarification in this regard, please correspond directly with the claimant at the address
mentioned in the claim form.

Yours faithfully,

Asst. General Manager/ Chief Manager/Branch Manager

Copy for information nominee/ claimant.

The captioned claim with related annexure as mentioned above submitted by you have been
forwarded to United India Insurance Company Ltd. at the recorded address. However, please note
that all future correspondence in this regard should be made directly with the Insurance Company
without involving the Bank. Admissibility of claim will be decided by the Insurance Company as per
the Insurance Policy. The claim settlement will entirely be the responsibility of Insurance Company.
All settlement/ disputes will be between the claimant and the Insurance Company and the Bank will
not be a party to such disputes.

Asst. General Manager/ Chief Manager/Branch Manager

(Branch Stamp)