{"id":112,"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_Kannada.pdf","sha256":"e58341ffeb2414f0b8b3d028d28abd82a78eb56c288e46add8947ffae5e1b90a","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for hospital authorities to certify details related to a non-accidental death claim under a life insurance policy. It is filled by the hospital and the attending doctor.","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":"Enter the insurance policy number","type":"text","label":"Policy No/ ŸÌÐ ಸಂĤƮ","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the deceased","type":"text","label":"Full Name of the Deceased/ ಮರಣũಂÂದ ವƮ±Ƥಯ ಸಂđಣರ್ Ńಸñ","options":[],"required":null,"pdf_field":""},{"help":"Enter the name","type":"text","label":"Name/ Ńಸñ","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age/ ವಯöƶ","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"In Years/ ವಷರ್ಗø","options":[],"required":null,"pdf_field":""},{"help":"Enter occupation of the deceased","type":"text","label":"Occupation/ ಉŚƮೕಗ","options":[],"required":null,"pdf_field":""},{"help":"Enter address of the deceased","type":"text","label":"Address/ ͬಸ","options":[],"required":null,"pdf_field":""},{"help":"Enter any identification mark if available","type":"text","label":"Identification mark (if any) / ÙñÀನ Ùñæ (ಇದƦĽ)","options":[],"required":false,"pdf_field":""},{"help":"Enter date of hospital admission","type":"date","label":"Date of admission/ œಖ¦Àಯ žಂಕ","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission","type":"text","label":"Time/ ಸಮಯ","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital admission number","type":"text","label":"Admission number/ œಖľ ಸಂĤƮ","options":[],"required":false,"pdf_field":""},{"help":"Describe nature and duration of illness at admission","type":"text","label":"Nature and Duration of illness reported at the time of Admission/ œಖ¦Àಯ ಸಮಯದÌƲ ವರ¤ದ ţೕಗದ ಸƳ¢ವ ಮæƤ ಅವÃ","options":[],"required":null,"pdf_field":""},{"help":"Provide referral details if applicable","type":"text","label":"If the patient was referred to you, please state the / ţೕ³ಯêƨ Äಮĥ Ľಫರ್ £½ದƦĽ, ದಯÍáƟ ģಳ³ನ £ÑÀಯêƨ Äೕ½","options":[],"required":false,"pdf_field":""},{"help":"Enter name of hospital or doctor","type":"text","label":"Name of the Hospital/Doctor concerned / ಸಂಬಂÃತ ಆಸƩIJƯ /—ಕƟರ್ Ńಸñ","options":[],"required":null,"pdf_field":""},{"help":"Enter address of hospital or doctor","type":"text","label":"Address of the Hospital/Doctor concerned / ಸಂಬಂÃತ ಆಸƩIJƯ /—ಕƟರ್ ͬಸ","options":[],"required":null,"pdf_field":""},{"help":"Provide history of illness at admission","type":"text","label":"History of illness reported at the time of admission/ œಖ¦Àಯ ಸಮಯದÌƲ ವರ¤ದ ţೕಗದ ಇÀ«ಸ","options":[],"required":null,"pdf_field":""},{"help":"Name the person who reported the illness history","type":"text","label":"Who reported the history of illness?/ ţೕಗದ ಇÀ«ಸವêƨ ¤ñ ವರ £½ದñ?","options":[],"required":false,"pdf_field":""},{"help":"Provide details of doctor who recorded illness history","type":"text","label":"Please give details of doctor who recorded the history of illness/ ţೕಗದ ಇÀ«ಸ œಖÌÐದ —ಕƟರ್ Íವರಗಳêƨ Äೕ½","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Diagnosis and Treatment Details","fields":[{"help":"Enter hospital diagnosis","type":"text","label":"What was the diagnosis arrived at in the Hospital?/ ಆಸƩIJƯಯÌƲ ತòÅದ Äಣರ್ಯ ಏê?t","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 / ಮರಣũಂÂದ ವƮ±Ƥĥ Äೕಡ¦ದ ¶±IJƶಯ Íವರಗಳêƨ Äೕ½. ಅಗತƮÍದƦĽ ಪƯIJƮೕಕ «ńಗಳêƨ Őೕ½Ð","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./ ಆಸƩIJƯĥ œಖ¦Àಯ ಸಮಯದÌƲ ಇñವ ಅಥ§ ÑಂÂನ ಇತರ ¤óĴೕ ţೕಗ/ಅಸƳಸƥIJಗÒದƦĿļ? ಸಂÓಪƤ Íವರಗಳêƨ Äೕ½.","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/ ಅವñ ÑಂÂನ ಅವÃಯÌƲ ಈ ţೕಗ ಅಥ§ ಇತರ ¤óĴೕ ţೕಗ‹ƕ³ ಆಸƩIJƯĥ œಖ¦³ ¶±IJƶ ಪįÂದƦĽ, Íವರಗಳêƨ Äೕ½","options":[],"required":false,"pdf_field":""},{"help":"Describe patient's condition at discharge","type":"text","label":"Condition at the time of discharge/ ½ªƚಜ್ರ್ ಸಮಯದ ÐƥÀ","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Certification by Hospital and Doctor","fields":[{"help":"Tick to certify correctness of information","type":"checkbox","label":"Certified that the above information is correct as per records of the Hospital / ĻೕÌನ £ÑÀಗø ಆಸƩIJƯಯ œಖľಗಳ ಪƯ‹ರ ಸˤ³Ŀ ಎಂè ಪƯ£¿ೕಕËಸ¦³Ĵ","options":["Certified"],"required":true,"pdf_field":""},{"help":"Enter hospital name","type":"text","label":"Name of the Hospital/ ಆಸƩIJƯಯ Ńಸñ","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital postal address","type":"text","label":"Postal Address of the Hospital/ ಆಸƩIJƯಯ ಅಂĨ ͬಸ","options":[],"required":true,"pdf_field":""},{"help":"Affix hospital seal or stamp","type":"signature","label":"Hospital Seal/ Stamp / ಆಸƩIJƯಯ ïèĽ/ïĴƯ","options":[],"required":true,"pdf_field":""},{"help":"Enter doctor's name","type":"text","label":"Name of the Doctor/ —ಕƟರ್ Ńಸñ","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date/ žಂಕ","options":[],"required":true,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Signature/ ಸÑ","options":[],"required":true,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration No./ Ŝಂದ¿ ಸಂĤƮ","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification/ ಅಹರ್IJ","options":[],"required":true,"pdf_field":""},{"help":"Doctor's designation","type":"text","label":"Designation/ ÷ĴƦ","options":[],"required":false,"pdf_field":""},{"help":"Enter telephone number with STD code","type":"phone","label":"Telephone No. (with STD code)/ Ďರ§¿ ಸಂĤƮ (ಎಸ್ »½ ʼnೕಡ್ ŜಂÂĥ)","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) / ಆಸƩIJƯಯÌƲ ¶±IJƶŋøƸವ ಅವÃಯÌƲ £½ದ ತŸಸı ಮæƤ ಪËೕŅಗಳ Íವರಗø «ÿ žಂಕಗಳêƨ Äೕ½. (ಆದĽ ನಕòಗಳêƨ ಸಂಲ³ƨÐ)","options":[],"required":false,"pdf_field":""},{"help":"Provide details of investigations and tests","type":"text","label":"Details of the investigations and tests/ ತŸಸı ಮæƤ ಪËೕŅಗಳ Íವರಗø","options":[],"required":false,"pdf_field":""},{"help":"Date of investigations/tests","type":"date","label":"Date/ žಂಕ","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital and 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 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/112-hospital-treatment-certificate-non-accidental-death-claim"}