{"id":100,"title":"Claim Form - Covid 19 Rider","purpose":"claim","insurer":{"slug":"bandhan-life-insurance","name":"Bandhan Life Insurance Limited"},"source_pdf":"https://www.bandhanlife.com/sites/default/files/asset/2026-04/COVID-19%20Rider%20Claim%20form_Urdu.pdf","sha256":"205f26d5aff88b5da0f315e4296cc3bfe6ae1b59df7b75f4f4690a2840fdf3a7","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for claiming the Covid-19 Rider benefit under a Bandhan Life Insurance policy. It is to be filled by the claimant who is entitled to receive the policy monies.","notes":["Form must be filled in BLOCK letters.","Only the person entitled to receive the policy monies under the policy shall fill and sign the form.","Rider benefit is payable only if the policy is in force on the date of hospitalization and other policy conditions are met.","Regulatory guidelines require payouts to be credited directly to the bank account of the beneficiary; hence bank details and a cancelled cheque or passbook copy are mandatory.","If claimant signs with thumb impression or vernacular signature, a witness declaration is required.","Use self-attested copies for all documents."],"title":"Claim Form - Covid 19 Rider","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claimant Details","fields":[{"help":"Fill in the insured person's details including name, gender, date of birth, complete address, certificate of insurance number, mobile number, master policy number, and email.","type":"text","label":"Details of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Full name of the insured person","type":"text","label":"Insured name","options":[],"required":true,"pdf_field":""},{"help":"Select the gender of the insured","type":"choice","label":"Gender Male/Female/Third Gender","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Date of birth of the insured","type":"date","label":"Date of birth","options":[],"required":true,"pdf_field":""},{"help":"Full postal address of the insured","type":"text","label":"Complete address","options":[],"required":true,"pdf_field":""},{"help":"Insurance certificate number","type":"text","label":"Certificate of insurance no.","options":[],"required":true,"pdf_field":""},{"help":"Mobile phone number of the insured or claimant","type":"phone","label":"Mobile No","options":[],"required":true,"pdf_field":""},{"help":"Master policy number","type":"text","label":"Master policy no.","options":[],"required":true,"pdf_field":""},{"help":"Email address of the insured or claimant","type":"email","label":"Email","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details","fields":[{"help":"Name of the bank for payout","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of the bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Hospitalization Details","fields":[{"help":"Name of the hospital where insured was admitted","type":"text","label":"Name of hospital","options":[],"required":true,"pdf_field":""},{"help":"Full address of the hospital","type":"text","label":"Complete address of the hospital","options":[],"required":true,"pdf_field":""},{"help":"Date when the insured was admitted","type":"date","label":"Date of admission","options":[],"required":true,"pdf_field":""},{"help":"Date when the insured was discharged","type":"date","label":"Date of discharge","options":[],"required":true,"pdf_field":""},{"help":"MICR code of the bank branch","type":"text","label":"MICR code","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Covid-19 Diagnosis Details","fields":[{"help":"Date when Covid-19 was diagnosed","type":"date","label":"Date of diagnosis of Covid-19","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration & Authorization","fields":[{"help":"Sign or affix left thumb impression","type":"signature","label":"Signature/ Left thumb impression of claimant","options":[],"required":true,"pdf_field":""},{"help":"Name of witness if claimant signs with thumb impression or vernacular signature","type":"text","label":"Name of witness","options":[],"required":false,"pdf_field":""},{"help":"Address of the witness","type":"text","label":"Address of witness","options":[],"required":false,"pdf_field":""},{"help":"Signature of the witness","type":"signature","label":"Signature of witness","options":[],"required":false,"pdf_field":""},{"help":"Phone number of the witness","type":"phone","label":"Contact no. of witness","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Covid 19 Rider claims","attachments":["Claim form duly filled & signed","Copy of Hospital discharge summary","Copy of Covid-19 test report & other lab reports","KYC documents of claimant","PAN or Form No 60","Copy of any one of the following (Identity & address proof of claimant): Valid Passport, Valid Driving License, Voter’s Identity Card, Job Card issued by NREGA duly signed by an officer of State Government","Proof of possession of Aadhar number (first 8 digits to be masked) in such a form as issued by the Unique Identification authority of India (Aadhar Card)","Copy of self-attested cancelled cheque bearing pre-printed name of beneficiary/Passbook copy of the claimant"],"declarations":["The claimant declares that all answers and statements are true and that submitting this form does not admit any insurance liability by the company.","The claimant consents to Bandhan Life Insurance Ltd. obtaining all relevant records and conducting investigations as deemed fit.","Payment of claim amount shall constitute discharge of liability of Bandhan Life Insurance Ltd.","If the claimant signs in vernacular or with thumb impression, a witness must sign a declaration confirming the claimant understood the form."],"dropped_labels":3},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"submit duly completed claim forms and other documents at the nearest Bandhan Life Branch Office or at our Head Office","label":"Claim Intimation and Registration","level":null,"hours":null,"applies_to":"life","source_url":"https://www.bandhanlife.com/customer-service/claims-process","quote":"nes can use the amount when they need it most.\nClaim Intimation and Registration\nFor Claims intimation to Bandhan Life, submit duly completed claim forms and other documents at the nearest Bandhan Life Branch Office or at our Head Office. Please click on the below links to see/ download the requirement list, claim forms and to locate our nearest branch of","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/bandhan-life-insurance/100-claim-form-covid-19-rider"}