{"id":117,"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_Telugu.pdf","sha256":"295636e7bb8225da387f5f235a07fe0d757eda7fb757de45c76862a467ed342c","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is to be filled by the hospital to certify details related to a non-accidental death claim under a life insurance policy. It is filled by hospital authorities and the treating doctor based on hospital 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":"Patient and Admission Details","fields":[{"help":"Enter the insurance policy number","type":"text","label":"Policy No/ పాలసీ సంఖƟ","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the deceased","type":"text","label":"Full Name of the Deceased/ మరణించిన వƟకిƕ యొకƅ పూరిƕ పేరు","options":[],"required":null,"pdf_field":""},{"help":"Enter the name","type":"text","label":"Name/ పేరు","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age/ వయసుƧ In Years/ సంవతƧరాలు","options":[],"required":null,"pdf_field":""},{"help":"Enter occupation of the deceased","type":"text","label":"Occupation/ వృతిƕ","options":[],"required":null,"pdf_field":""},{"help":"Enter address of the deceased","type":"text","label":"Address/ చిరునామా","options":[],"required":null,"pdf_field":""},{"help":"Enter any identification mark if present","type":"text","label":"Identification mark (if any) / గురిƕ ంపు గురుƕ (ఉంటే)","options":[],"required":false,"pdf_field":""},{"help":"Enter date of hospital admission","type":"date","label":"Date of admission/ దాఖలైన తేదీ","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission","type":"text","label":"Time/ సమయం","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital admission number","type":"text","label":"Admission number/ అడిƞషన నంబర","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/ అడిƞషన సమయంలో నివేదించబడిన వాƟధి సƤభావం మరియు వƟవధి","options":[],"required":null,"pdf_field":""},{"help":"Enter referral details if applicable","type":"text","label":"If the patient was referred to you, please state the / రోగిని మీకు రిఫర చేసినటơ యితే, దయచేసి పేరొƄనండి","options":[],"required":false,"pdf_field":""},{"help":"Enter name of referring hospital or doctor","type":"text","label":"Name of the Hospital/Doctor concerned / సంబంధిత హాసిƚటల/డాకƐ ర పేరు","options":[],"required":null,"pdf_field":""},{"help":"Enter address of referring hospital or doctor","type":"text","label":"Address of the Hospital/Doctor concerned / సంబంధిత హాసిƚటల/డాకƐ ర చిరునామా","options":[],"required":false,"pdf_field":""},{"help":"Provide history of illness at admission","type":"text","label":"History of illness reported at the time of admission/ అడిƞషన సమయంలో నివేదించబడిన వాƟధి చరితƠ","options":[],"required":null,"pdf_field":""},{"help":"Enter name of person who reported illness history","type":"text","label":"Who reported the history of illness?/ వాƟధి చరితƠ ను ఎవరు నివేదించారు?","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/ వాƟధి చరితƠ ను నమోదు చేసిన డాకƐ ర వివరాలు ఇవƤండి","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?/ హాసిƚటల లో నిరాƘ రణ ఏమిటి?","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 / మరణించిన వƟకిƕ కి అందించిన చికితƧ వివరాలు ఇవƤండి. అవసరమైతే వేరే షీటుƢ జతచేయండి","options":[],"required":null,"pdf_field":""},{"help":"Mention any other illnesses before or during 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./ అడిƞషన సమయంలో ఉనƙ వాƟధితో పాటు లేదా మునుపు ఉనƙ ఇతర వాƟధుల గురించి సంకి̀పƕ ంగా వివరించండి","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/ ఆఖరి వాƟధి లేదా ఇతర వాƟధికి హాసిƚటల లో మునుపెనƙడైనా చికితƧ పొందారా? అయితే వివరాలు ఇవƤండి","options":[],"required":false,"pdf_field":""},{"help":"Describe patient's condition at discharge","type":"text","label":"Condition at the time of discharge/ డిశాƊరƌ్ సమయంలో పరిసిƖ తి","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Hospital and Doctor Certification","fields":[{"help":"Enter hospital name","type":"text","label":"Name of the Hospital/ హాసిƚటల పేరు","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital postal address","type":"text","label":"Postal Address of the Hospital/ హాసిƚటల తపాలా చిరునామా","options":[],"required":null,"pdf_field":""},{"help":"Affix hospital seal or stamp","type":"signature","label":"Hospital Seal/ Stamp హాసిƚటల ముదƠ / సా Ɛ ప్","options":[],"required":null,"pdf_field":""},{"help":"Enter doctor's name","type":"text","label":"Name of the Doctor/ డాకƐ ర పేరు","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date/ తేదీ","options":[],"required":null,"pdf_field":""},{"help":"Doctor's signature","type":"signature","label":"Signature/ సంతకం","options":[],"required":null,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration No./ నమోదు నం.","options":[],"required":null,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification/ అరƨ త","options":[],"required":null,"pdf_field":""},{"help":"Doctor's designation","type":"text","label":"Designation/ హోదా","options":[],"required":false,"pdf_field":""},{"help":"Enter telephone number with STD code","type":"phone","label":"Telephone No. (with STD code)/ టెలిఫోన నంబర (ఎస టీడి కోడ తో)","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital and doctor"},{"title":"Investigations and Tests","fields":[{"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) / హాసిƚటల లో ఉండిన సమయంలో చేసిన పరిశోధనలు మరియు పరీక̀ల వివరాలు, తేదీలు ఇవƤండి. (ఉంటే నకలులు జతచేయండి)","options":[],"required":false,"pdf_field":""},{"help":"Provide details of investigations and tests","type":"text","label":"Details of the investigations and tests/ పరిశోధనలు మరియు పరీక̀ల వివరాలు","options":[],"required":false,"pdf_field":""},{"help":"Date of investigations/tests","type":"date","label":"Date/ తేదీ","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Non-accidental death claims under life insurance policies","attachments":["Separate sheets for treatment details if required","Copies of investigations and tests conducted during hospital stay"],"declarations":["The information provided is certified 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/117-hospital-treatment-certificate-non-accidental-death-claim"}