{"id":107,"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_Gujarati.pdf","sha256":"643fa62b217f7588497dde80d280a807be673fd25d176fceccfd659a1495d56d","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for claiming non-accidental death benefits under a policy and is to be filled and signed by the person entitled to receive the policy monies.","notes":["Only the person entitled to receive the policy monies under the policy shall fill and sign the form.","Information should be based on hospital records."],"title":"HOSPITAL TREATMENT CERTIFICATE – NON-ACCIDENTAL DEATH CLAIM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Deceased 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":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age In Years","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Describe any identification mark if present","type":"text","label":"Identification mark (if any)","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Admission number","options":[],"required":false,"pdf_field":""},{"help":"Describe illness and duration as reported at admission","type":"text","label":"Nature and Duration of illness reported at the time of Admission","options":[],"required":null,"pdf_field":""},{"help":"Provide name of referring hospital or doctor if applicable","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":"Provide address of referring hospital or doctor if applicable","type":"text","label":"Address of the Hospital/Doctor concerned","options":[],"required":false,"pdf_field":""},{"help":"Describe history of illness as reported at admission","type":"text","label":"History of illness reported at the time of admission","options":[],"required":null,"pdf_field":""},{"help":"Name the person who reported the illness history","type":"text","label":"Who reported the history of illness?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of the doctor who recorded the illness history","type":"text","label":"Please give details of doctor who recorded the history of illness","options":[],"required":false,"pdf_field":""},{"help":"List investigations and tests with their dates; attach copies if available","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":"person entitled to receive policy monies"},{"title":"Diagnosis and Treatment Details","fields":[{"help":"Provide the hospital diagnosis","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":null,"pdf_field":""},{"help":"Mention any other illnesses present at 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":"Provide 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":"Describe patient's condition at discharge","type":"text","label":"Condition at the time of discharge","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Certification by Hospital","fields":[{"help":"","type":"text","label":"Name of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Postal Address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Affix hospital seal or stamp","type":"signature","label":"Hospital Seal/ Stamp","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Doctor","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Signature","options":[],"required":null,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Doctor's designation","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Hospital or doctor's phone number with STD code","type":"phone","label":"Telephone No. (with STD code)","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Non-accidental death claims","attachments":["Copies of investigations and tests conducted during hospital stay","Separate sheets for treatment details if required"],"declarations":["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/107-hospital-treatment-certificate-non-accidental-death-claim"}