{"id":114,"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_Marathi.pdf","sha256":"d7f86d37882c30a26b6914431c2e75f765c0dee621d598cd564749c886b9fce9","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for claiming non-accidental death insurance benefits and is to be filled and signed by the person entitled to receive the policy monies under the policy.","notes":["Only the person entitled to receive the policy monies under the policy shall fill and sign the form","Attach copies of investigations and tests if available","Attach separate sheets if treatment details exceed space provided"],"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/ पॉ󰇒लसी 󰈚मांक","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Full Name of the Deceased/ मृतक का पूरा नाम","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name/ नाव","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age/ वय In Years/ वषा󰇠म󰇸ये","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation/ 󰈄यवसाय","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address/ प󰊋ा","options":[],"required":null,"pdf_field":""},{"help":"Describe any identification mark if present","type":"text","label":"Identification mark (if any) / ओळख खूण (जर असेल तर)","options":[],"required":false,"pdf_field":""},{"help":"Enter date and time of admission","type":"date","label":"Date of admission/ दाखल हो󰇴याची तारीख Time/ वेळ","options":[],"required":null,"pdf_field":""},{"help":"Hospital admission number","type":"text","label":"Admission number/ 󰈯वेश 󰈚मांक","options":[],"required":null,"pdf_field":""},{"help":"Describe illness nature and duration at admission","type":"text","label":"Nature and Duration of illness reported at the time of Admission/ भरती󰇪या वेळी नमूद केले󰈂या आजाराचा 󰈯कार व कालावधी","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 / संबं󰇐धत 󰊁󰇧णालयाचे/डॉ󰇥टरचे नाव","options":[],"required":false,"pdf_field":""},{"help":"Address of referring hospital or doctor if applicable","type":"text","label":"Address of the Hospital/Doctor concerned / संबं󰇐धत 󰊁󰇧णालयाचा/डॉ󰇥टरचा प󰊋ा","options":[],"required":false,"pdf_field":""},{"help":"Provide history of illness at admission","type":"text","label":"History of illness reported at the time of admission/ भरती󰇪या वेळी नमूद केलेला आजाराचा इ󰇎तहास","options":[],"required":null,"pdf_field":""},{"help":"Name of person who reported illness history","type":"text","label":"Who reported the history of illness?/ आजाराचा इ󰇎तहास कोणी सां󰇏गतला?","options":[],"required":null,"pdf_field":""},{"help":"Details of doctor who recorded illness history","type":"text","label":"Please give details of doctor who recorded the history of illness/ आजाराचा इ󰇎तहास नो󰇝दवणा󰈀या डॉ󰇥टरचे तपशील कृपया 󰊣ा","options":[],"required":null,"pdf_field":""},{"help":"List investigations and tests with 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) / 󰊁󰇧णालयात उपचारा󰇪या कालावधीत कर󰇴यात आले󰈂या तपास󰇴या व चाच󰇴यांचे तपशील आ󰇑ण 󰇎दनांक कृपया 󰊣ा. (अस󰈂यास कृपया 󰈯ती जोडा󰈄यात)","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Diagnosis and Treatment Details","fields":[{"help":"Enter hospital diagnosis","type":"text","label":"What was the diagnosis arrived at in the Hospital?/ 󰊁󰇧णालयात कोणते 󰇎नदान कर󰇴यात आले होते?","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 / मृत 󰈄य󰊊󰇛स 󰇎दले󰈂या उपचारांचे तपशील कृपया 󰊣ा. आव󰈅यक अस󰈂यास वेगळी प󰈪के जोडावीत.","options":[],"required":null,"pdf_field":""},{"help":"Mention any other illness present before or 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./ 󰊁󰇧णालयात भरती󰇪या वेळी संबं󰇐धत आजाराबरोबर कोणताही इतर आजार पूवी󰇟पासून होता का? अस󰈂यास 󰈘याचे सं󰇑󰊈󰇺त तपशील 󰊣ा.","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/ 󰈘याच आजारासाठी 󰇎क󰇝वा इतर कोण󰈘याही आजारासाठी पूवी󰇟 󰊁󰇧णालयात उपचार झाले होते का? होय अस󰈂यास कृपया तपशील 󰊣ा.","options":[],"required":false,"pdf_field":""},{"help":"Describe patient's condition at discharge","type":"text","label":"Condition at the time of discharge/ 󰇎ड󰈈चाज󰇟󰇪या वेळी 󰊁󰇧णाची 󰇔󰈈थती","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Hospital Certification","fields":[{"help":"Hospital to certify correctness of information","type":"checkbox","label":"Certified that the above information is correct as per records of the Hospital / 󰈯मा󰇑णत कर󰇴यात येते क󰇛 वरील मा󰇎हती 󰊁󰇧णालया󰇪या नो󰇝दीनुसार बरोबर आहे.","options":["Certified"],"required":true,"pdf_field":""},{"help":"Hospital name","type":"text","label":"Name of the Hospital/ 󰊁󰇧णालयाचे नाव","options":[],"required":true,"pdf_field":""},{"help":"Hospital postal address","type":"text","label":"Postal Address of the Hospital/ 󰊁󰇧णालयाचा टपाल प󰊋ा","options":[],"required":true,"pdf_field":""},{"help":"Hospital official seal or stamp","type":"signature","label":"Hospital Seal/ Stamp 󰊁󰇧णालयाची 󰇑श󰇥का","options":[],"required":true,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of the Doctor/ डॉ󰇥टरचे नाव","options":[],"required":true,"pdf_field":""},{"help":"Date of certification","type":"date","label":"Date/ 󰇎दनांक:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Signature/ 󰈈वा󰊈री","options":[],"required":true,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration No./ नो󰇝दणी 󰈚मांक","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification/ शै󰊈󰇑णक पा󰈪ता","options":[],"required":true,"pdf_field":""},{"help":"Doctor's designation","type":"text","label":"Designation/ पदनाम","options":[],"required":true,"pdf_field":""},{"help":"Hospital or doctor's telephone number with STD code","type":"phone","label":"Telephone No. (with STD code)/ 󰊆र󰇸वनी 󰈚मांक (एसटीडी कोडसह)","options":[],"required":true,"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 additional treatment details if required"],"declarations":["The person entitled to receive the policy monies must fill and sign the form","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/114-hospital-treatment-certificate-non-accidental-death-claim"}