{"id":116,"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_Tamil.pdf","sha256":"0f37037632f7b6917d1c1c977590624edde9cec23da7becc6df771692b7f87b8","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for claiming non-accidental death insurance benefits and is to be filled by the hospital based on their records.","notes":["Only the person entitled to receive the policy monies under the policy shall fill & 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":"Deceased and Admission Details","fields":[{"help":"","type":"text","label":"Policy No/ காப்பீட்டு எண்","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Full Name of the Deceased/ இறந்தவரின் முழுப்ெபயர்","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name/ ெபயர்","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age/ வயது In Years/ ஆண்டுகள்","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation/ ெதாழில்","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address/ முகவரி","options":[],"required":null,"pdf_field":""},{"help":"If any identification mark exists","type":"text","label":"Identification mark (if any) / அைடயாள குறி (ஏேதனும் இருந்தால்)","options":[],"required":false,"pdf_field":""},{"help":"Date of hospital admission","type":"date","label":"Date of admission/ ேசர்க்கப்பட்ட ேததி","options":[],"required":null,"pdf_field":""},{"help":"Time of admission","type":"text","label":"Time/ ேநரம்","options":[],"required":false,"pdf_field":""},{"help":"Hospital admission number","type":"text","label":"Admission number/ ேசர்க்ைக எண்","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/ ேசர்க்ைகயின் ேபாது குறிப்பிடப்பட்ட ேநாயின் தன்ைம மற்றும் கால அளவு","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 / பரிந்துைரக்கப்பட்ட மருத்துவமைன/மருத்துவரின் ெபயர்","options":[],"required":false,"pdf_field":""},{"help":"Address of referring hospital or doctor","type":"text","label":"Address of the Hospital/Doctor concerned / பரிந்துைரக்கப்பட்ட மருத்துவமைன/மருத்துவரின் முகவரி","options":[],"required":false,"pdf_field":""},{"help":"History of illness at admission","type":"text","label":"History of illness reported at the time of admission/ ேசரும் ேபாது பதிவுெசய்யப்பட்ட ேநாயின் வரலாறு","options":[],"required":null,"pdf_field":""},{"help":"Person who reported the illness history","type":"text","label":"Who reported the history of illness?/ ேநாயின் வரலாற்ைற யார் அறிவித்தார்?","options":[],"required":null,"pdf_field":""},{"help":"Doctor who recorded illness history","type":"text","label":"Please give details of doctor who recorded the history of illness/ ேநாயின் வரலாற்ைற பதிவு ெசய்த மருத்துவரின் விவரங்கைள தயவுெசய்து குறிப்பிடவும்","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Diagnosis, Treatment and Hospital Stay Details","fields":[{"help":"Final diagnosis in hospital","type":"text","label":"What was the diagnosis arrived at in the Hospital?/ மருத்துவமைனயில் எடுக்கப்பட்ட ேநாயறிதல் என்ன?","options":[],"required":null,"pdf_field":""},{"help":"Details of 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 / மரணமைடந்தவருக்கு அளிக்கப்பட்ட சிகிச்ைசயின் விவரங்கைள தயவுெசய்து குறிப்பிடவும். ேதைவப்பட்டால் தனி தாள்கைள இைணக்கவும்","options":[],"required":null,"pdf_field":""},{"help":"Other illnesses 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./ மருத்துவமைனயில் ேசரும் ேபாது அல்லது அதற்கு முன்ேப ஏேதனும் பிற ேநாய்கள்/ேநாய்கள் இருந்தனவா. அதன் சுருக்கமான விவரங்கைள வழங்கவும்.","options":[],"required":false,"pdf_field":""},{"help":"Previous hospital treatments if any","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/ அவருக்கு கடந்த ேநாயுக்கு அல்லது பிற ேநாய்களுக்கு முன்பு மருத்துவமைனயில் சிகிச்ைச அளிக்கப்பட்டதா? ஆம் என்றால், விவரங்கைள அளிக்கவும்","options":[],"required":false,"pdf_field":""},{"help":"Patient's condition at discharge","type":"text","label":"Condition at the time of discharge/ வீடு திரும்பும் ெபாழுதான நிைல","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 / ேமலுள்ள தகவல்கள் மருத்துவமைனயின் பதிவுகளின்படி சரியானைவ எனச் சான்றளிக்கப்படுகிறது","options":["Certified"],"required":true,"pdf_field":""},{"help":"Hospital name","type":"text","label":"Name of the Hospital/ மருத்துவமைனயின் ெபயர்","options":[],"required":true,"pdf_field":""},{"help":"Hospital postal address","type":"text","label":"Postal Address of the Hospital/ மருத்துவமைனயின் அஞ்சல் முகவரி","options":[],"required":true,"pdf_field":""},{"help":"Hospital seal or stamp","type":"signature","label":"Hospital Seal/ Stamp / மருத்துவமைன முத்திைர/முத்திைர அைடயாளம்","options":[],"required":true,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of the Doctor/ மருத்துவரின் ெபயர்","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date/ ேததி","options":[],"required":true,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Signature/ ைகெயாப்பம்","options":[],"required":true,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration No./ பதிேவடு எண்","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification/ தகுதி","options":[],"required":true,"pdf_field":""},{"help":"Doctor's designation","type":"text","label":"Designation/ பதவி","options":[],"required":true,"pdf_field":""},{"help":"Hospital or doctor's telephone number with STD code","type":"phone","label":"Telephone No. (with STD code)/ ெதாைலேபசி எண் (எஸ்டிடி குறியீட்டுடன்)","options":[],"required":false,"pdf_field":""},{"help":"Details and dates of investigations/tests; 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) / மருத்துவமைனயில் தங்கியிருந்தேபாது ேமற்ெகாள்ளப்பட்ட ஆய்வுகள் மற்றும் பரிேசாதைனகளின் விவரங்கள் மற்றும் ேததிகைள தயவுெசய்து வழங்கவும். (இருந்தால் நகல்கைள இைணக்கவும்)","options":[],"required":false,"pdf_field":""},{"help":"Details of investigations and tests","type":"text","label":"Details of the investigations and tests/ ஆய்வுகள் மற்றும் பரிேசாதைனகளின் விவரங்கள்","options":[],"required":false,"pdf_field":""},{"help":"Date of investigations/tests","type":"date","label":"Date/ ேததி","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 (if available)"],"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/116-hospital-treatment-certificate-non-accidental-death-claim"}