{"id":118,"title":"Hospital Treatment Certificate/ APS - Accidental Disability/ Dismemberment 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%20-%20Disability.pdf","sha256":"f425b74c0428a1fba04ab489403f157e5ddcb5ad9630408dd2a5db445cf43390","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for hospitals to provide medical and accident details for an accidental disability or dismemberment claim under a life insurance policy.","notes":["Please furnish details in separate sheets if required"],"title":"Hospital Treatment Certificate/ APS - Accidental Disability/ Dismemberment Claim","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Patient and Accident Details","fields":[{"help":"Enter the insurance policy number","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the insured person","type":"text","label":"Full Name of the Life Assured","options":[],"required":null,"pdf_field":""},{"help":"Enter the patient's full name","type":"text","label":"a) Name","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years, months","type":"number","label":"b) Age","options":[],"required":null,"pdf_field":""},{"help":"Enter patient's occupation","type":"text","label":"c) Occupation","options":[],"required":null,"pdf_field":""},{"help":"Enter patient's address","type":"text","label":"d) Address","options":[],"required":null,"pdf_field":""},{"help":"Enter any identification mark on the patient","type":"text","label":"e) Identification mark (if any)","options":[],"required":false,"pdf_field":""},{"help":"Enter the date when the accident occurred","type":"date","label":"2) a) Date of Accident","options":[],"required":null,"pdf_field":""},{"help":"Enter time of accident with am/pm","type":"text","label":"b) Time of Accident","options":[],"required":null,"pdf_field":""},{"help":"Enter location of accident","type":"text","label":"c) Place of Accident","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital admission date","type":"date","label":"3) a) Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission with am/pm","type":"text","label":"b) Time of Admission","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital admission number if any","type":"text","label":"c) Admission Number","options":[],"required":false,"pdf_field":""},{"help":"Select the nature of accident","type":"choice","label":"4) a) Nature of Accident","options":["RTA","Worksite","Others"],"required":null,"pdf_field":""},{"help":"Describe the accident (e.g. Road Traffic Accident, Drowning)","type":"text","label":"a. Description of the Accident","options":[],"required":null,"pdf_field":""},{"help":"Describe injuries sustained","type":"text","label":"b. Nature of Injury/ies suffered by the Insured (whether self-inflicted or otherwise)","options":[],"required":null,"pdf_field":""},{"help":"Provide name and contact of doctor who recorded history","type":"text","label":"e) Name and contact number of the doctor who recorded history","options":[],"required":null,"pdf_field":""},{"help":"Enter referring hospital or doctor details if applicable","type":"text","label":"5) If the injured was referred to you, please state the Name & Address of the Hospital/ Doctor concerned","options":[],"required":false,"pdf_field":""},{"help":"Provide details if accident involved influence of substances","type":"text","label":"6) Did the accident occur under the influence of alcohol/drugs/narcotics or any non-prescribed medicine","options":[],"required":false,"pdf_field":""},{"help":"List investigation dates and details; attach copies","type":"table","label":"7) Please provide details and dates of the investigations conducted during the stay in the hospital. (if so please attach copies)","options":[],"required":false,"pdf_field":""},{"help":"Describe treatment or surgery; use separate sheets if needed","type":"text","label":"8) Please give details of the treatment/rendered to/surgical procedure undergone by the insured.","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital diagnosis","type":"text","label":"9) What was the diagnosis arrived at in the Hospital?","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Disability Details and Discharge Information","fields":[{"help":"Describe the disability or dismemberment","type":"text","label":"10) Please Describe the exact type of Dismemberment/Disability suffered as a consequence of the accident as mentioned above","options":[],"required":null,"pdf_field":""},{"help":"Select whether impairment is temporary or permanent","type":"choice","label":"11) Nature of impairment","options":["Temporary","Permanent"],"required":null,"pdf_field":""},{"help":"Provide details of any pre-existing conditions","type":"text","label":"12) Are you aware of any illness/ disease, disorder (including any psychic or mental disorder) which the insured was suffering from prior to this accident? If yes, give brief particulars of it","options":[],"required":false,"pdf_field":""},{"help":"Enter discharge date","type":"date","label":"13) Date of discharge from Hospital","options":[],"required":null,"pdf_field":""},{"help":"Describe patient's condition at discharge","type":"text","label":"14) Condition at the time of discharge","options":[],"required":null,"pdf_field":""},{"help":"Mention any follow-up treatment recommended","type":"text","label":"15) Follow up treatment advised","options":[],"required":false,"pdf_field":""},{"help":"Provide prognosis details","type":"text","label":"16) What is the prognosis?","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"choice","label":"17) Was the accident reported to the police?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide police station details and report date/time if applicable","type":"text","label":"If so, please furnish the name and address of the police station and the date and time of the report","options":[],"required":false,"pdf_field":""},{"help":"Confirm if disability is solely due to accident injuries","type":"text","label":"18) Was the Disability/Dismemberment of the Insured caused solely by injuries suffered by him in the accident?","options":[],"required":null,"pdf_field":""},{"help":"Provide any additional relevant information","type":"text","label":"19) Any other information, which you consider, would be vital in the claim review process under this policy?","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Certification and Signature","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of the certifying doctor","type":"signature","label":"Signature","options":[],"required":null,"pdf_field":""},{"help":"Enter doctor's name","type":"text","label":"Name of Doctor","options":[],"required":null,"pdf_field":""},{"help":"Doctor's code number if any","type":"text","label":"Code no","options":[],"required":false,"pdf_field":""},{"help":"Enter doctor's qualification and designation","type":"text","label":"Qualification & Designation","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital name","type":"text","label":"Hospital Name","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital address","type":"text","label":"Hospital Address","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital contact number","type":"phone","label":"Contact No","options":[],"required":false,"pdf_field":""},{"help":"Affix hospital stamp","type":"attachment","label":"Hospital Stamp","options":[],"required":null,"pdf_field":""}],"filled_by":"doctor/hospital"}],"deadlines":[],"applies_to":"Accidental Disability / Dismemberment Claim under Policy No.","attachments":["Copies of investigations conducted during hospital stay"],"declarations":["Certified that the above information is true and correct as per the records of the Hospital"],"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/118-hospital-treatment-certificate-aps-accidental-disability-dismemberment-claim"}