{"id":111,"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_Oriya.pdf","sha256":"2cbb8bcf62b5c5a46e69e2f38b7eb21bf1e2aa9b758d9d06cf46e2afb07f0606","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is to be filled by the hospital to provide medical details and certification for a non-accidental death claim under a life insurance policy.","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":"Patient and Admission Details","fields":[{"help":"Enter the insurance policy number","type":"text","label":"Policy No","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the deceased person","type":"text","label":"Full Name of the Deceased","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the deceased","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Age in completed years","type":"number","label":"In Years","options":[],"required":null,"pdf_field":""},{"help":"Enter the occupation of the deceased","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Enter the residential address of the deceased","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter any identification mark on the deceased","type":"text","label":"Identification mark (if any)","options":[],"required":false,"pdf_field":""},{"help":"Date when the patient was admitted","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":null,"pdf_field":""},{"help":"Describe the illness and its duration as reported on 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 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":"Medical history as reported on admission","type":"text","label":"History of illness reported at the time of admission","options":[],"required":null,"pdf_field":""},{"help":"Name or relation of the person who reported the history","type":"text","label":"Who reported the history of illness?","options":[],"required":null,"pdf_field":""},{"help":"Name and details of the doctor who recorded the history","type":"text","label":"Please give details of doctor who recorded the history of illness","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Diagnosis and Treatment Details","fields":[{"help":"Final diagnosis made by the 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 at 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":""}],"filled_by":"hospital"},{"title":"Hospital Certification and Doctor's Details","fields":[{"help":"Confirm accuracy of information","type":"checkbox","label":"Certified that the above information is correct as per records of the Hospital","options":["Yes"],"required":true,"pdf_field":""},{"help":"Enter hospital name","type":"text","label":"Name of the Hospital","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital postal address","type":"text","label":"Postal Address of the Hospital","options":[],"required":true,"pdf_field":""},{"help":"Affix 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":"Doctor's contact number including STD code","type":"phone","label":"Telephone No. (with STD code)","options":[],"required":false,"pdf_field":""},{"help":"List investigations and tests with dates; attach copies if available","type":"text","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 performed","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"}],"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 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/111-hospital-treatment-certificate-non-accidental-death-claim"}