Claim Form

Please Fill in the Form Completely: Incomplete filled claim form shall not be accepted.

Factory / Organization

Factory / Organization Name: Organization Regn. No:
Factory / Organization Address: Insurance No:


Name of the Insured :
Age : Sex :
Last Residence Address :
Sl. No : ID/JOB No :
Date : NID No :
Date of Joining : Date of Last attendance at work :


Nature of Claim :
Claim Sl No of the factory / organization : Date of Notification to organization :
Place of Incident : Date & Time of Incident :


Name of Nominee : Relationship with Nominee :
Address of Nominee :

Enclosed supporting Document (Please put a serial number on each document)

For Death Claim

Death Certificate from a Registered Doctor :
Employment Certificate :
ID Card/Job Card :
Services Book :
Attendance Sheet (last three months) :
Salary Statement (last three months) :
Leave Approval Sheet (if death during leave) :
Appointment Letter (if death before enlistment) :

Additionally for Accidental Death

FIR Report :
Post-Mortem Report or Waiver Certificate :
News Paper Report (if any) :

For Disability Claim

Employer's Statement of Injury :
Photograph of the Concerned Person :
Physician's Certificate :

We hereby certify that the statement furnished above and the Document enclosed herewith are true and complete to the best of our knowledge. We hereby authorize all physicians, hospitals, clinics, pharmacists, laboratories,previous employers, any institutions or any other person who has any record or information about the insured to provide Sonali Life Insurance Company Limited any and all information with respect to the claim including medical history, consultation, prescription, treatments and copies of all hospital or medical records. Any copy of this authorization shall be considered as original.

We hereby warrant that the said employee was in our payroll continously from the date of his/her insurance to the date of incident. We know and fully agree that, incase information furnished above or the enclosed Document are found untrue, the company shall have the right to decline the claim.

Head office

Rupali Bima Bhaban,
7 RAJUK Avenue,

Extended Office

68/B D.I.T. Road, Malibagh Chowdhury Para, Dhaka-1219.


Customer Support: 01976625488, 01976625499
IP Phone: 09678200004

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