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]
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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]
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