Last Attending Physician`s Statement - Proof Of Death
MetLife India Insurance Company Limited. (Insurance Regulatory and Development Authority Life Insurance Registration No. 117) Registered Office: ‘Brigade Seshamahal’, 5, Vani Vilas Road, Basavanagudi, Bangalore - 560 004, www.metlife.co.in, Fax: +91-80-4150 6969 Last Attending Physician's Statement - Proof Of Death In the interest of accurate vital statistics, please conform to the International List of the causes of death PLEASE SIGN ON ALL PAGES AT BOTTOM. Name of the deceased’s Physician: _____________________________________________________________________ Name of the clinic / Hospital : _________________________________________________________________________ Address : ________________________________________________________________________________________ Contact No. _______________________ E-mail address : _______________________________ About the Insured/Deceased: Name of the deceased / patient : _______________________________________________________________________ Address: __________________________________________________________________________________________ Age & Sex: __________________________ Date of Death: Hospital/Indoor Patient Number: _________________________________ Time of Death: Place of Death (if hospital or institution, please give the name & address) Date of first consultation Date of last consultation What were the symptoms / illness/ disease? Duration of symptoms/illness/disease Which investigations/ tests were performed: Date of Diagnosis: What was the diagnosis Interval between onset and death ______________ Yrs _____________ Months ____________ Days Antecedent causes (morbid conditions, if any, giving rise to the above cause of death): A (Due to) Customer Service Toll free: 1800-425-6969, OR Call on: +91 -80 -2650 -2244 (8:00 am to 8:00 PM) Write to us at [email protected] Page 1 of 2 MetLife India Insurance Company Limited. (Insurance Regulatory and Development Authority Life Insurance Registration No. 117) Registered Office: ‘Brigade Seshamahal’, 5, Vani Vilas Road, Basavanagudi, Bangalore - 560 004, www.metlife.co.in, Fax: +91-80-4150 6969 Last Attending Physician's Statement - Proof Of Death B (Due to) Other significant conditions (contributing to the death but not related to the disease or condition causing death) Was the patient informed of your findings and/or diagnosis? Have you treated or advised the deceased during the past five years, prior to final illness? Please give details: Was there any consultation with any other medical practitioner/hospital prior to your consultation/s? Please provide details: Please provide brief medical history of the deceased and history provided by: If death was due to accident, suicide, or homicide, please specify and provide the death summary: Was an inquest held? Yes No Was an autopsy performed? Yes No If yes, by whom was the autopsy conducted and with what findings? Has this patient, to your knowledge, used tobacco products? Yes No Don’t Know DECLARATION: These statements are true and complete to the best of my knowledge and belief. Name & Signature of the Physician: ______________________________________________ Date ___________________________ Qualifications _______________________________________________________ Reg. No. ____________________________________________________________ (Seal) Customer Service Toll free: 1800-425-6969, OR Call on: +91 -80 -2650 -2244 (8:00 am to 8:00 PM) Write to us at [email protected] Page 2 of 2
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