PNB MetLife India Insurance Company Limited

Registered office: Brigade Seshamahal, 5 Vani Vilas Road, Basavanagudi, Bangalore-560004, Karnataka. IRDA of India Registration number 117. CI No. U66010KA2001PLC028883)
Call us Toll-free at 1-800-425-6969, Website: www.pnbmetlife.com, Email: indiaservice@pnbmetlife.co.in or write to us at 1st Floor, Techniplex -1, Techniplex Complex, Off Veer
Savarkar Flyover, Goregaon (West), Mumbai – 400062. Phone: +91-22-41790000, Fax: +91-22-41790203

VERNACULAR DECLARATION FORMAT

(To be filled only if Death Certificate is received in Vernacular Language)

Policy Number: ___________________________ Name of Person Insured: _________________________

Name of the Beneficiary/ Claimant: ______________________________________________________________

Identity proof submitted by the Beneficiary/ Claimant: _______________________________________________

This is to certify that following is the extract of information that has been mentioned in the Death certificate
received for the deceased life assured Late Sh./Smt.…………………………… which is available in
……………………….(name of language).

Name of the deceased (as per Death Certificate)

Name of Father/Spouse
Gender
Date of Death
Place of Death
Permanent Address, if mentioned in attached
death certificate
Registration No/Sl. No. of Death Certificate
Date of Registration(DD-MM-YYYY)
Death Certificate issued by (Name of Municipal
Council/state along with place)

I hereby declare that above details are true and correct as per the particulars mentioned in the death certificate
issued by the Registrar of Death of …………………………………….. (Name of place) in
..…………………………… (Name of state). I hereby declare that appropriate legal action can be initiated by
PNB MetLife against me in case the above mentioned details, as contained in the Death Certificate is found to be
untrue or false.

(To be signed by the Beneficiary/Claimant)

Above declaration is filled in presence of

Name of BSM: ……………………….. Signature: ………………………….

Date: …./…./……… (DD-MM-YYYY) Place: …………………………………

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