{"id":108,"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_Bengali.pdf","sha256":"b4781ca52ae323ac19965fe6447edfd30a49385c6d319e5a61c2e2241710222e","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for claiming death benefits under a life insurance policy and must be filled by the person entitled to receive the policy monies.","notes":["Information should be based on hospital records","Only the person entitled to receive policy monies should fill and 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/ পিলিস নȼর","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Full Name of the Deceased/ মৃত বঁিƐর পূণ˿ নাম","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name/ নাম","options":[],"required":null,"pdf_field":""},{"help":"In Years/ বছের","type":"number","label":"Age/ বয়স","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation/ েপশা","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address/ ˙কানা","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Identification mark (if any) / সনাƐকারী িচʂ (যিদ থােক)","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date of admission/ ভিতঁর তািরখ","options":[],"required":null,"pdf_field":""},{"help":"Time of admission","type":"text","label":"Time/ সময়","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Admission number/ ভিতঁ নȼর","options":[],"required":false,"pdf_field":""},{"help":"Describe illness and duration at admission","type":"text","label":"Nature and Duration of illness reported at the time of Admission/ ভিতঁর সময় জানােনা েরােগর Ȣকৃিত ও ɵািয়ǰকাল","options":[],"required":null,"pdf_field":""},{"help":"Details of referral if any","type":"text","label":"If the patient was referred to you, please state the / েরাগীেক আপনার কােছ েরফার করা হেয় থাকেল, অনুƨহ কের উেɔখ করুন","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the Hospital/Doctor concerned / সȸিকঁত হাসপাতাল/িচিকৎসেকর নাম","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of the Hospital/Doctor concerned / সȸিকঁত হাসপাতাল/িচিকৎসেকর ˙কানা","options":[],"required":null,"pdf_field":""},{"help":"History of illness at admission","type":"text","label":"History of illness reported at the time of admission/ ভিতঁর সময় জানােনা েরােগর ইিতহাস","options":[],"required":null,"pdf_field":""},{"help":"Person who reported illness history","type":"text","label":"Who reported the history of illness?/ েরােগর ইিতহাস েক জািনেয়িছেলন?","options":[],"required":false,"pdf_field":""},{"help":"Doctor who recorded illness history","type":"text","label":"Please give details of doctor who recorded the history of illness/ েরােগর ইিতহাস িযিন িলিপবǸ কেরেছন, েসই িচিকৎসেকর িবɱািরত তথঁ িদন","options":[],"required":false,"pdf_field":""},{"help":"List investigations/tests and 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) / হাসপাতােল ভিতঁ থাকার সময় েয সকল পরীƘা-িনরীƘা করা হেয়েছ, েসƠেলার িবɱািরত তথঁ ও তািরখ িদন। (যিদ েথেক থােক, অনুƩহ কের তার অনুিলিপ সংযুƐ করুন)","options":[],"required":false,"pdf_field":""},{"help":"Details of investigations/tests","type":"text","label":"Details of the investigations and tests/ পরীƘা-িনরীƘার িবɱািরত তথঁ","options":[],"required":false,"pdf_field":""},{"help":"Date of investigations/tests","type":"date","label":"Date/ তািরখ","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Diagnosis and Treatment Details","fields":[{"help":"Final diagnosis at hospital","type":"text","label":"What was the diagnosis arrived at in the Hospital?/ হাসপাতােল িগেয় েয েরাগ িনণ˿য় করা হেয়িছল তা কী িছল?","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 / মৃত বঁিƐেক ȢদǨ িচিকৎসার িবɱািরত িববরণ িদন। Ȣেয়াজেন আলাদা কাগজ সংযুƐ করুন।","options":[],"required":null,"pdf_field":""},{"help":"Details of any other illness 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./ ভিতঁর সময় িবদঁমান েরােগর পাশাপািশ পূেব˿ েকােনা অসুɵতা/েরাগ িছল িক? থাকেল তার সংিƘȜ িববরণ িদন।","options":[],"required":false,"pdf_field":""},{"help":"Details of any previous treatment in this hospital","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/ এই েশষ অসুɵতা বা অনঁ েকােনা অসুɵতার জনঁ পূেব˿ িক তােক এই হাসপাতােল িচিকৎসা েদওয়া হেয়িছল? হেয় থাকেল অনুƩহ কের িবɱািরত িদন।","options":[],"required":false,"pdf_field":""},{"help":"Patient's condition at discharge","type":"text","label":"Condition at the time of discharge/ ছাড়পǮ েদওয়ার সময় েরাগীর অবɵা","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Certification by Hospital/Doctor","fields":[{"help":"Confirm accuracy of above information","type":"checkbox","label":"Certified that the above information is correct as per records of the Hospital / Ȣমািণত করা যােƺ েয উপেরর তথঁসমূহ হাসপাতােলর েরকড˿ অনুযায়ী স˙ক।","options":["Certified"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Hospital/ হাসপাতােলর নাম","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Postal Address of the Hospital/ হাসপাতােলর ডাক ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Hospital official seal or stamp","type":"signature","label":"Hospital Seal/ Stamp  হাসপাতােলর িসল/েমাহর","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Doctor/ িচিকৎসেকর নাম","options":[],"required":true,"pdf_field":""},{"help":"Date of certification","type":"date","label":"Date/ স˙ক।","options":[],"required":true,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Signature/ ɻাƘর","options":[],"required":true,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration No./ িনবȒন নȼর","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification/ েযাগঁতা","options":[],"required":true,"pdf_field":""},{"help":"Doctor's designation","type":"text","label":"Designation/ পদিব","options":[],"required":true,"pdf_field":""},{"help":"Hospital or doctor's phone number with STD code","type":"phone","label":"Telephone No. (with STD code)/ েটিলেফান নȼর (এস˘িড েকাডসহ)","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 treatment details if required"],"declarations":["The person entitled to receive the policy monies must fill and sign the form","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/108-hospital-treatment-certificate-non-accidental-death-claim"}