{"id":109,"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_Malayalam.pdf","sha256":"b0cb5e984bde5accb9bf6af1394d60025454ea9a7d5b4bfb3b2b401d2cd6f722","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for claiming death benefits under a life insurance policy and must 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","Attach separate sheets if treatment details are lengthy","Attach copies of investigations and tests if available"],"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 completed 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 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 how long it lasted 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 if applicable","type":"text","label":"If the patient was referred to you, please state the","options":[],"required":false,"pdf_field":""},{"help":"Name of hospital or doctor providing treatment","type":"text","label":"Name of the Hospital/Doctor concerned","options":[],"required":null,"pdf_field":""},{"help":"Address of hospital or doctor","type":"text","label":"Address of the Hospital/Doctor concerned","options":[],"required":null,"pdf_field":""},{"help":"Details of illness history as reported at admission","type":"text","label":"History of illness reported at the time of admission","options":[],"required":null,"pdf_field":""},{"help":"Name or relation of person who reported illness history","type":"text","label":"Who reported the history of illness?","options":[],"required":false,"pdf_field":""},{"help":"Name and details of doctor who recorded illness history","type":"text","label":"Please give details of doctor who recorded the history of illness","options":[],"required":false,"pdf_field":""}],"filled_by":"person entitled to claim"},{"title":"Treatment and Hospitalization Details","fields":[{"help":"Final diagnosis made 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":null,"pdf_field":""},{"help":"Mention any other illnesses present 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. Give brief particulars of it.","options":[],"required":false,"pdf_field":""},{"help":"Details of any prior 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 when discharged","type":"text","label":"Condition at the time of discharge","options":[],"required":null,"pdf_field":""},{"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":"Official hospital seal or stamp","type":"signature","label":"Hospital Seal/ Stamp","options":[],"required":true,"pdf_field":""},{"help":"Doctor's full name","type":"text","label":"Name of the Doctor","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","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":""},{"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)","options":[],"required":false,"pdf_field":""},{"help":"Details of investigations and tests conducted","type":"text","label":"Details of the investigations and tests","options":[],"required":false,"pdf_field":""},{"help":"Date of investigations/tests","type":"date","label":"Date","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital/doctor"}],"deadlines":[],"applies_to":"Non-accidental death claims","attachments":["Separate sheets for treatment details if required","Copies of investigations and tests conducted during hospital stay"],"declarations":["The person entitled to receive 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/109-hospital-treatment-certificate-non-accidental-death-claim"}