{"id":115,"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_Urdu.pdf","sha256":"a66a219af24c4972237ee79b45922f07ae04ff9d7624128daade08317bf3a4fd","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for the claimant entitled to receive policy monies to provide hospital treatment details related to a non-accidental death claim, based on hospital records.","notes":["Attach copies of investigations and tests conducted during hospital stay","Attach separate sheets if treatment details exceed space","Form must be filled and signed by the person entitled to claim","Hospital seal/stamp and doctor's signature are mandatory"],"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 complete name of the deceased","type":"text","label":"Full Name of the Deceased","options":[],"required":null,"pdf_field":""},{"help":"Enter the name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Specify age in years","type":"text","label":"In Years","options":[],"required":null,"pdf_field":""},{"help":"Enter occupation of the deceased","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Enter full address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Describe any identification mark","type":"text","label":"Identification mark (if any)","options":[],"required":null,"pdf_field":""},{"help":"Enter date of hospital admission","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital admission number","type":"text","label":"Admission number","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","options":[],"required":null,"pdf_field":""},{"help":"Provide referring hospital or doctor's name","type":"text","label":"If the patient was referred to you, please state the name of the Hospital/Doctor concerned","options":[],"required":null,"pdf_field":""},{"help":"Provide address of referring hospital or doctor","type":"text","label":"Address of the Hospital/Doctor concerned","options":[],"required":null,"pdf_field":""},{"help":"Provide history of illness as reported at admission","type":"text","label":"History of illness reported at the time of admission","options":[],"required":null,"pdf_field":""},{"help":"Name the person who reported the illness history","type":"text","label":"Who reported the history of illness?","options":[],"required":null,"pdf_field":""},{"help":"Provide details of the doctor who recorded illness history","type":"text","label":"Please give details of doctor who recorded the history of illness","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Hospital Diagnosis and Treatment Details","fields":[{"help":"List investigations/tests and their dates; attach copies if available","type":"table","label":"Details and dates of the investigations and tests conducted during the stay in the hospital","options":[],"required":null,"pdf_field":""},{"help":"Provide hospital diagnosis","type":"text","label":"What was the diagnosis arrived at in the Hospital?","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment given; use 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 into the hospital. Give brief particulars of it.","options":[],"required":null,"pdf_field":""},{"help":"Provide 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":null,"pdf_field":""},{"help":"Describe patient's condition at discharge","type":"text","label":"Condition at the time of discharge","options":[],"required":null,"pdf_field":""},{"help":"Hospital to certify correctness 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":"Enter doctor's 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":null,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Doctor's designation","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Doctor's telephone number including STD code","type":"phone","label":"Telephone No. (with STD code)","options":[],"required":null,"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":["Only the person entitled to receive the policy monies shall 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/115-hospital-treatment-certificate-non-accidental-death-claim"}