{"id":106,"title":"HOSPITAL TREATMENT CERTIFICATE – NON-ACCIDENTAL DEATH CLAIM","purpose":"claim","insurer":{"slug":"bandhan-life-insurance","name":"Bandhan Life Insurance Limited"},"source_pdf":"https://www.bandhanlife.com/sites/default/files/asset/2026-04/Hospital%20Treatment%20Certificate-Death_English.pdf","sha256":"86dba905b20885fd84f7a36acdc9b6f153196cbd00ed2dacba3fe93a9bbb3622","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the claimant entitled to receive policy monies to provide hospital treatment details related to a non-accidental death claim. The claimant fills and signs the form based on hospital records.","notes":["Only the person entitled to receive the policy monies under the policy shall fill & sign the form"],"title":"HOSPITAL TREATMENT CERTIFICATE – NON-ACCIDENTAL DEATH CLAIM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Patient and Admission Details","fields":[{"help":"","type":"text","label":"Policy No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Full Name of the Deceased","options":[],"required":null,"pdf_field":""},{"help":"Name of the deceased","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Age of the deceased in years","type":"number","label":"Age In Years","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Address of the deceased","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Any identifying mark on the deceased","type":"text","label":"Identification mark (if any)","options":[],"required":false,"pdf_field":""},{"help":"Date when the deceased was admitted to hospital","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"Time of admission","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"Hospital admission number","type":"text","label":"Admission number","options":[],"required":false,"pdf_field":""},{"help":"Describe illness nature and duration at admission","type":"text","label":"Nature and Duration of illness reported at the time of Admission","options":[],"required":null,"pdf_field":""},{"help":"Name of referring hospital or doctor","type":"text","label":"If the patient was referred to you, please state the Name of the Hospital/Doctor concerned","options":[],"required":false,"pdf_field":""},{"help":"Address of referring hospital or doctor","type":"text","label":"Address of the Hospital/Doctor concerned","options":[],"required":false,"pdf_field":""},{"help":"History of illness as reported on admission","type":"text","label":"History of illness reported at the time of admission","options":[],"required":null,"pdf_field":""},{"help":"Person who reported the illness history","type":"text","label":"Who reported the history of illness?","options":[],"required":false,"pdf_field":""},{"help":"Doctor's details who recorded illness history","type":"text","label":"Please give details of doctor who recorded the history of illness","options":[],"required":false,"pdf_field":""},{"help":"List investigations/tests and their dates; attach copies","type":"table","label":"Please provide details and dates of the investigations and tests conducted during the stay in the hospital. (if so please attach copies)","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Diagnosis and Treatment Details","fields":[{"help":"Final diagnosis by hospital","type":"text","label":"What was the diagnosis arrived at in the Hospital?","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment given; attach extra sheets if needed","type":"text","label":"Please give details of the treatment rendered to the deceased. Attach separate sheets if required","options":[],"required":false,"pdf_field":""},{"help":"Details of any other illnesses before or during admission","type":"text","label":"Were there any other illness/disease prior to or which coexisted with the ailment at the time of admission into the hospital. Give brief particulars of it.","options":[],"required":false,"pdf_field":""},{"help":"Details of any previous hospital treatments","type":"text","label":"Was he/she treated in the hospital on any previous occasion for the last illness or any other illness? If yes, please give details","options":[],"required":false,"pdf_field":""},{"help":"Patient's condition at discharge","type":"text","label":"Condition at the time of discharge/ छु󰊎ी के समय क󰇛 󰇔󰈈थ󰇎त","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Hospital Certification","fields":[{"help":"Hospital certifies correctness of information","type":"checkbox","label":"Certified that the above information is correct as per records of the Hospital","options":["Certified"],"required":true,"pdf_field":""},{"help":"Hospital name","type":"text","label":"Name of the Hospital","options":[],"required":true,"pdf_field":""},{"help":"Hospital postal address","type":"text","label":"Postal Address of the Hospital","options":[],"required":true,"pdf_field":""},{"help":"Hospital official seal or stamp","type":"signature","label":"Hospital Seal/ Stamp","options":[],"required":true,"pdf_field":""},{"help":"Doctor's name certifying the form","type":"text","label":"Name of the Doctor","options":[],"required":true,"pdf_field":""},{"help":"Date of certification","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration No.","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"Doctor's designation","type":"text","label":"Designation","options":[],"required":true,"pdf_field":""},{"help":"Hospital or doctor's telephone number with STD code","type":"phone","label":"Telephone No. (with STD code)","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital doctor"}],"deadlines":[],"applies_to":"non-accidental death claims","attachments":["Copies of investigations and tests conducted during hospital stay","Separate sheets for additional treatment details if required"],"declarations":["The hospital certifies that the information provided is correct as per hospital records"],"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/106-hospital-treatment-certificate-non-accidental-death-claim"}