Disability and Dismemberment Claim

Claim Forms (Download this form in other Language)
For Disability:
1. Part I: Application Form for Critical Illness ( Life Assured's Statement)
2. Part II: Confidential Medical Report (to be filled by attending physician)
For Dismemberment:
1. Part I: Application Form for Dismemberment ( Life Assured's Statement)
2. Part II: Dismemberment Claim Form – (attending Physician's report)
Attested True Copy of Indoor Case Papers of the hospital
Discharge Summary of present and past hospitalizations
Photo Identity of Life Assured with age and address proof (List of acceptable ID and Address proofs of claimant)
Bank Details of the claimant – Cancelled cheque (with printed name and account number)/bank passbook and NEFT Form
All related Medical Examination Reports, e.g.
1. Laboratory test reports
2. X-Ray / CT Scan / MRI Reports & Plates
3. Ultrasonography Report
4. Clinical / Hospital Reports
Disability Certificate by attending physician / Institute for disabled
Rehabilitation Certificate - if applicable
Employer's written confirmation / statement - for Disability claim
Clinical Photographs showing the injured areas - if available

Hospitalisation is due to accidental causes (submit in addition to the above)

All police reports / First Information Report & Final Investigation Report - if due to accidental cause

Please Note:

Please submit copies of the following documents certified / attested by the issuing authority. ( Original Seen Verified (OSV) by Branch Personnel will also be accepted) -
1. All Police papers – Panchnama, Inquest, First Information Report and Final Investigation Report
2. Medical Records (Admission Notes, Discharge/Death Summary, Indoor Case Papers, Test Reports etc)
Copies of the other documents to be submitted by self attestation of the claimant
In case the claim warrants any additional requirement, TALIC reserves the right to call for the same.
Notification of claim & submission of the claim requirements does not mean admission of the claim liability by the Company.
No agent is authorized to admit any liabilities on behalf of the Company, nor to alter this list of documents or any claims requirements called for by the Company.