{"id":104,"title":"Claim Form - Covid 19 Rider / ਕਲੇਮ ਫਾਰਮ-ਕੋਿਵਡ 19 ਰਾਈਡਰ","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_Punjabi.pdf","sha256":"013a04b0eedc869a1ad5f6ca38d613942384aa58ab71b2955ca7b37638b09975","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the claimant entitled to receive policy monies under the Covid-19 Rider of Bandhan Life Insurance to claim the rider benefit after hospitalization due to Covid-19.","notes":["Form must be filled in BLOCK letters.","Only the person entitled to receive policy monies shall fill and sign the form.","Rider benefit is payable subject to policy being in force on the date of hospitalization and other policy conditions.","Regulatory guidelines require payout to be credited directly to beneficiary's bank account; attach self-attested cancelled cheque or bank passbook copy.","If claimant signs in vernacular or thumb impression, witness must sign the vernacular declaration.","Witness can be a person of local standing, Special Executive Magistrate, Notary, Lawyer, or Class 1 Gazette Officer."],"title":"Claim Form - Covid 19 Rider / ਕਲੇਮ ਫਾਰਮ-ਕੋਿਵਡ 19 ਰਾਈਡਰ","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claimant and Insured Details","fields":[{"help":"","type":"text","label":"City/ ਸ਼ਿਹਰ","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State / ਰਾਜ","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pincode / ਿਪੰਨ ਕੋਡ","options":[],"required":null,"pdf_field":""},{"help":"Full name of the insured person","type":"text","label":"Insured name/ ਬੀਮਾ ਹੋਏ ਿਵਅਕਤੀ ਦਾ ਨਾਮ","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender/ ਿਲੰਗ","options":["Male/ ਪੁਰਸ਼","Female/ ਮਿਹਲਾ","Third Gender/ ਤੀਸਰਾ ਿਲੰਗ"],"required":null,"pdf_field":""},{"help":"Date format as DD/MM/YYYY","type":"date","label":"Date of birth/ ਜਨਮ ਤਾਰੀਖ","options":[],"required":null,"pdf_field":""},{"help":"Full residential address","type":"text","label":"Complete address/ ਪੂਰਾ ਪਤਾ","options":[],"required":null,"pdf_field":""},{"help":"Insurance certificate number","type":"text","label":"Certificate of insurance no./ ਬੀਮਾ ਸਰਟੀਿਫਕੇਟ ਨੰਬਰ","options":[],"required":null,"pdf_field":""},{"help":"10 digit mobile number","type":"phone","label":"Mobile No/ ਮੋਬਾਈਲ ਨੰਬਰ","options":[],"required":null,"pdf_field":""},{"help":"Master policy number","type":"text","label":"Master policy no./ ਮਾਸਟਰ ਪਾਿਲਸੀ ਨੰਬਰ","options":[],"required":null,"pdf_field":""},{"help":"Valid email address","type":"email","label":"Email/ ਈਮੇਲ ਆਈਡੀ","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/ ਬƷ ਕ ਦਾ ਨਾਮ","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of the bank branch","type":"text","label":"IFSC Code/ ਆਈਐਫਐਸਸੀ ਕੋਡ","options":[],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No/ ਖਾਤਾ ਨੰਬਰ","options":[],"required":true,"pdf_field":""},{"help":"Select the type of bank account","type":"choice","label":"Account Type/ ਖਾਤਾ ਿਕਸਮ","options":["Savings/ ਬਚਤ","Current/ ਚਾਲੂ"],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Hospitalization Details","fields":[{"help":"Name of the hospital where admitted","type":"text","label":"Name of hospital/ ਹਸਪਤਾਲ ਦਾ ਨਾਮ","options":[],"required":null,"pdf_field":""},{"help":"MICR code of the hospital bank branch","type":"text","label":"MICR code/ ਆਈਐਫਐਸਸੀ ਕੋਡ","options":[],"required":null,"pdf_field":""},{"help":"Full address of the hospital","type":"text","label":"Complete address of the hospital/ ਹਸਪਤਾਲ ਦਾ ਪੂਰਾ ਪਤਾ","options":[],"required":null,"pdf_field":""},{"help":"Date format as DD/MM/YYYY","type":"date","label":"Date of admission/ ਭਰਤੀ ਹੋਣ ਦੀ ਿਮਤੀ","options":[],"required":null,"pdf_field":""},{"help":"Time of admission","type":"text","label":"Time/ ਸਮਾਂ","options":[],"required":null,"pdf_field":""},{"help":"Date format as DD/MM/YYYY","type":"date","label":"Date of discharge/ ਛੁੱਟੀ ਦੀ ਿਮਤੀ","options":[],"required":null,"pdf_field":""},{"help":"Time of discharge","type":"text","label":"Time/ ਸਮਾਂ","options":[],"required":null,"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\nਦਾਅਵਾ ਕਰਤਾ ਦੇ ਦਸਤਖਤ/ਖੱਬੇ ਅੰਗੂਠੇ ਦਾ ਿਨਸ਼ਾਨ","options":[],"required":true,"pdf_field":""},{"help":"Name of the witness if claimant signs in vernacular or thumb impression","type":"text","label":"Name of witness / ਗਵਾਹ ਦਾ ਨਾਮ","options":[],"required":null,"pdf_field":""},{"help":"Address of the witness","type":"text","label":"Address of witness/ ਗਵਾਹ ਦਾ ਪਤਾ","options":[],"required":null,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of witness/ ਗਵਾਹ ਦੇ ਦਸਤਖਤ","options":[],"required":null,"pdf_field":""},{"help":"Phone number of the witness","type":"phone","label":"Contact no. of witness/ ਗਵਾਹ ਦਾ ਸੰਪਰਕ ਨੰਬਰ","options":[],"required":null,"pdf_field":""},{"help":"Date when Covid-19 was diagnosed","type":"date","label":"Date of diagnosis of Covid-19/ ਕੋਿਵਡ-19 ਦੀ ਪਛਾਣ ਦੀ ਿਮਤੀ","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Covid-19 Rider claims under Bandhan Life Insurance policies","attachments":["Claim form duly filled & signed / ਦਾਅਵਾ ਫਾਰਮ ਪੂਰੀ ਤਰǓ ਾਂ ਭਿਰਆ ਅਤੇ ਦਸਤਖਤ ਕੀਤਾ ਹੋਇਆ","Copy of Hospital discharge summary / ਹਸਪਤਾਲ ਤnj ਛੁੱਟੀ ਸੰਖੇਪ ਿਰਪੋਰਟ ਦੀ ਪǗ ਤੀ","Copy of Covid-19 test report & other lab reports / ਕੋਿਵਡ-19 ਜਾਂਚ ਿਰਪੋਰਟ ਅਤੇ ਹੋਰ ਲੈਬ ਿਰਪੋਰਟਾਂ ਦੀ ਪǗ ਤੀ","KYC documents of claimant / ਦਾਅਵਾ ਕਰਤਾ ਦੇ KYC ਦਸਤਾਵੇਜ਼","PAN or Form No 60 / ਪੈਨ ਜਾਂ ਫਾਰਮ ਨੰਬਰ 60","Copy of any one of the following (Identity & address proof of claimant) /  ਹੇਠ ਿਲਿਖਆਂ ਿਵਚnj ਿਕਸੇ ਇੱਕ ਦੀ ਪǗ ਤੀ (ਦਾਅਵਾ ਕਰਤਾ ਦੀ ਪਛਾਣ ਅਤੇ ਪਤਾ ਸਬੂਤ): 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 masked)","Copy of self-attested cancelled cheque bearing pre-printed name of beneficiary/Passbook copy of the claimant / ਲਾਭਪਾਤਰੀ ਦੇ ਨਾਮ ਨਾਲ ਿਪǗੰਟ ਕੀਤੀ ਹੋਈ ਖੁਦ-ਸਿਤਆਿਪਤ ਰੱਦ ਚƳ ਕ ਦੀ ਪǗ ਤੀ / ਦਾਅਵਾ ਕਰਤਾ ਦੀ ਪਾਸਬੁੱਕ ਦੀ ਪǗ ਤੀ"],"declarations":["The claimant declares that all answers and statements are true in all respects.","Submitting this form or any supplementary form does not constitute admission by the company that insurance was in force or waiver of any rights.","The claimant consents to Bandhan Life Insurance Ltd. and its representatives obtaining all relevant records and conducting investigations as deemed fit.","Payment of claim amount shall discharge Bandhan Life Insurance Ltd. of its liability.","If claimant signs in vernacular or affixes thumb impression, a witness must certify that the form contents were explained and understood."],"dropped_labels":0},"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/104-claim-form-covid-19-rider-19"}