{"id":130,"title":"Health Claim Form (Form – C)","purpose":"claim","insurer":{"slug":"canara-hsbc-life-insurance","name":"Canara HSBC Life Insurance Company Limited"},"source_pdf":"https://www.canarahsbclife.com/content/dam/chli/pdf/document-component/health-insurance-claims/claim-application.pdf","sha256":"948f72f091e7dde7de04d969e6b24dcc7e3b42a36416af29be885ad8d5a41c0b","pages":4,"collected":"2026-10-20","instructions":{"about":"This form is for submitting a health insurance claim by the person legally entitled to the policy monies, typically the claimant or nominee.","notes":["Claim settlement process does not require any payment of fee to anyone; report if asked.","Benefit payable only if policy is in force on date of event and terms are fulfilled.","Form to be filled by person legally entitled to policy monies.","Submission of form does not mean claim acceptance.","Attach self-attested photo ID proof and bank documents as specified.","Use additional sheets if needed for multiple claimants or doctors.","Declaration must be witnessed by authorized persons as listed.","Company may call for additional documents if required."],"title":"Health Claim Form (Form – C)","submit":{"to":"nearest branch/hub or at the address as indicated below","how":"","address":"Canara HSBC Life Insurance Company Limited, Orchid Business Park, 2nd Floor, Sector – 48, Sohna Road, Gurugram – 122018, Haryana, India"},"purpose":"claim","sections":[{"title":"Details of the Life Assured","fields":[{"help":"","type":"text","label":"Policy no(s):","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Other Health Policy no (s):","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Current Age years","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Residential Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Annual Income (p.a.) INR","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the employer (if salaried)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact no.","options":[],"required":null,"pdf_field":""},{"help":"Select the applicable claim type","type":"choice","label":"Claim submitted for: (Selecting the option does not confirm the admissibility of the claim.)","options":["Heart Cover- Minor condition","Heart Cover – Major condition","Cancer Cover - Minor condition","Cancer Cover- Major condition","Critical Illness"],"required":null,"pdf_field":""},{"help":"Provide any extra relevant details","type":"text","label":"Notes – Any additional information you would like to mention:","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Details of the Claimant","fields":[{"help":"Attach additional sheet if more than one claimant","type":"text","label":"Name(s)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relation to the life assured","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Mailing Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"E-mail ID","options":[],"required":false,"pdf_field":""},{"help":"Tick all applicable ID proofs attached","type":"checkbox","label":"Please enclose a copy of self attested photo ID proof (Please tick whichever is submitted)","options":["Passport","Driving License","Voter’s ID card","PAN card","AADHAR card","Company ID card","Other, please specify"],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Bank Details of the Claimant (MANDATORY)","fields":[{"help":"","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"Select the type of bank account","type":"choice","label":"Type of Account: Saving Current NRE NRO (In case of NRI Claimant, please provide NRO account number only)","options":["Saving","Current","NRE","NRO"],"required":true,"pdf_field":""},{"help":"Provide the bank's IFSC code","type":"text","label":"IFS Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Name and Address","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Details of illness/claim","fields":[{"help":"Describe symptoms and complaint","type":"text","label":"What was the nature of the complaint and the symptoms?","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment details","type":"text","label":"Please specify the treatment undertaken for the above complaint","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date when first symptoms of Illness noted","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Last Consultation/ hospitalization","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Include phone number","type":"text","label":"Name and Contact Number of treating Doctor","options":[],"required":null,"pdf_field":""},{"help":"Explain cause of illness","type":"text","label":"Detailed Description (giving cause)","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Doctors consulted in last 5 years","fields":[{"help":"Columns: S. No., Name & Address of the doctor with Contact no., Date of consultation / Diagnosis, Treatment Details","type":"table","label":"Name and addresses of all the doctors and usual doctor consulted by the life assured for any illness during the last 5 years","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Medical/Sick leave details in last 5 years","fields":[{"help":"Columns: Date From, Date To, Reasons as per Medical Certificate/ Leave Application, Diagnosis, Employer Insurance Availed Yes/No","type":"table","label":"Please give the details of the Medical/Sick leave taken in the last 5 years","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Other Life Insurance and Mediclaim policies","fields":[{"help":"Columns: S. No., Policy No., Name of Company, Policy Date, Basic Sum Assured (Rs.), Rider Benefit amount (Rs.), Claim Status","type":"table","label":"Details of Other Life Insurance and Mediclaim policies on the life of the life assured","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Declaration and Authorization","fields":[{"help":"Sign or provide left hand thumb impression; if illiterate, a witness must sign","type":"signature","label":"Declaration and Authorization","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature/left hand thumb impression (If illiterate) of Claimant 1","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature/left hand thumb impression (If illiterate) of Claimant 2","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Witness must be one of the specified company agents or bank officials","type":"signature","label":"Signature of Witness (Mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Witness must declare that form contents were explained in claimant's language","type":"text","label":"Declaration in case of an illiterate claimant/s","options":[],"required":true,"pdf_field":""},{"help":"Claimant to declare that contents were explained in their language and understood","type":"signature","label":"Declaration, if this form is signed in Vernacular/Thumb Impression","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"","attachments":["Original Policy Bond","Photo ID & address proof of the claimant (duly attested)","Copy of Bank Passbook/cancel cheque","Physician’s Statement","Hospital Certificate","Test/ Investigation reports including all the clinical treatments like, radiological, histological and laboratory test evidence (e.g. 2D echocardiogram,treadmill test,USG etc.) as applicable","Any report which gives us confirmation of diagnosis (Heart attack - ECG, Cardiac Injury Profile/ CABG - Surgical Notes and Angiography Reports/Cancer - Histopathology Report/Stroke - CT- SCAN, MRI Report and Neurological Opinion/Major Organ Transplant - Diagnosis of Original Report, Surgical Summary, Discharge Card/Kidney- Biopsy Report, Records of Haemodialysis)"],"declarations":["The information provided is true and claim settlement will be as per policy terms and conditions.","Authorization to share medical and financial information with the company and its agents for claim settlement.","A photocopy of this declaration is valid and effective.","Witness must be an authorized company agent or specified bank official.","If illiterate, a witness must declare that the form contents were explained in the claimant's language.","If signed in vernacular or thumb impression, claimant declares contents were explained and understood."],"dropped_labels":8},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/canara-hsbc-life-insurance/130-health-claim-form-form-c"}