{"id":131,"title":"Physician’s Statement","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/group-claims/english/physician-statement-group.pdf","sha256":"df6e5623c4f4920ffe85d98ec3d6f5f0d571de62a891b5fbc4fb7d7740ce57d7","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is to be filled by a qualified registered medical practitioner who attended the deceased insured person, to provide medical details for a death claim.","notes":["A separate Form P is to be filled by each medical practitioner who attended the deceased.","A qualified registered practitioner should fill in this form.","Attach medical records of treatment/consultation taken by the deceased."],"title":"Physician’s Statement","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Part I: Deceased and Doctor Details","fields":[{"help":"","type":"text","label":"Name and Address of the deceased","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Age at Death years Occupation","options":[],"required":null,"pdf_field":""},{"help":"If yes, specify the relationship","type":"choice","label":"Was the deceased related to you?    Yes     No          If yes, how?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Duration of acquaintance","type":"text","label":"How long did you know the deceased life assured?","options":[],"required":null,"pdf_field":""}],"filled_by":"physician"},{"title":"Part II: Death Details","fields":[{"help":"Provide date, time and place of death","type":"date","label":"Date and Time of Death          /       /         , :             (a.m. / p.m. ) ,Place of Death","options":["a.m.","p.m."],"required":null,"pdf_field":""}],"filled_by":"physician"},{"title":"Part III: Medical Details of Death","fields":[{"help":"","type":"text","label":"What was the immediate cause of death of the deceased?","options":[],"required":null,"pdf_field":""},{"help":"Duration of illness","type":"text","label":"How long did the deceased life assured suffer from this illness?","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"When did the deceased first consult you during his last illness?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"What were the symptoms/ complaints of the deceased at the time of consultation?","options":[],"required":null,"pdf_field":""},{"help":"Attach additional sheets if needed","type":"text","label":"What were the investigations undergone by the deceased to confirm the cause of death? (Please attach separate sheets if required)","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"When the diagnosis was finally confirmed?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"What was the treatment given to the deceased during the last illness or earlier?","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Did you treat the deceased during the whole course of the illness?                                             Yes       No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide start and end dates of consultation if not treated throughout","type":"text","label":"If No, then what was the period of consultation? / / to / /","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Did you refer the deceased to any other medical practitioner/ hospital for further treatment?      Yes       No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name, address and telephone of referred doctor/hospital","type":"text","label":"If yes, provide with the name and Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Was/ were there any other contributory illnesses/ chronic ailments suffered by the deceased that led to the death ?  Yes       No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of contributory illnesses","type":"text","label":"If yes, detail","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Were you the usual doctor of the deceased?  Yes       No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of usual doctor if different","type":"text","label":"(a) If no, provide the name of the usual doctor","options":[],"required":null,"pdf_field":""},{"help":"Duration as usual doctor","type":"text","label":"(b) If yes, then •   For how long","options":[],"required":null,"pdf_field":""},{"help":"Dates of consultations","type":"text","label":"•   Date of consultation (s)","options":[],"required":null,"pdf_field":""},{"help":"Diagnosis given","type":"text","label":"•   Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Treatment details","type":"text","label":"•   What was the treatment given?","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Did the deceased suffer from any other illness that led to the death?                                            Yes          No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of other illnesses","type":"text","label":"If yes, provide the details","options":[],"required":null,"pdf_field":""},{"help":"If yes, provide details","type":"choice","label":"Did you have reason to believe that the cause of death was due to the deceased’s own actions (eg self inflicted injury)   Yes No , if yes please provide details","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, provide details","type":"choice","label":"Was any Inquest or formal Inquiry held regarding the death or was a Post Mortem Examination of the body made? If yes, by whom and what was the result or finding?                                                                      Yes       No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Did the life assured have any adverse habits?                                                                               Yes         No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details and reasons","type":"text","label":"If yes, please detail Did these adverse habits led to the disease? (State reasons)","options":[],"required":null,"pdf_field":""},{"help":"List name, address and contact number of doctors who attended deceased in last 5 years","type":"table","label":"Please provide the details of the medical practitioners who had attended the deceased during the last 5 years Name Address Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Additional remarks","type":"text","label":"Please provide any additional relevant information/remarks that would help us in evaluation of this claim (deceased’s habits, ailments etc)","options":[],"required":null,"pdf_field":""}],"filled_by":"physician"},{"title":"Declaration and Signature","fields":[{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Medical Attendant","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Medical Attendant","options":[],"required":null,"pdf_field":""},{"help":"Official stamp","type":"text","label":"Stamp of Medical Attendant","options":[],"required":null,"pdf_field":""},{"help":"Medical registration number","type":"text","label":"Registration number","options":[],"required":null,"pdf_field":""},{"help":"Medical qualifications","type":"text","label":"Qualifications","options":[],"required":null,"pdf_field":""},{"help":"Address of medical attendant","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Contact number","type":"phone","label":"Telephone number","options":[],"required":null,"pdf_field":""}],"filled_by":"physician"}],"deadlines":[],"applies_to":"","attachments":["medical records of the treatment/ consultation taken by the deceased","separate sheets for investigations if required"],"declarations":["The medical attendant declares that the above statements are true and correct to the best of their knowledge and belief."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Claims Unit\nCanara HSBC Oriental Bank of Commerce Life Insurance Company Limited, 2nd Floor, Orchid Business Park , Sector-48, Sohna Road, Gurugram 122018, Haryana, India","label":"Claims Unit Address","level":null,"hours":null,"applies_to":"all","source_url":"https://irdai.gov.in/documents/37343/563751/136G046V01_2017-18.pdf/f050bed9-5535-1986-8392-ad04d16ecd43?version=1.1&t=1667553755436&download=true","quote":"he claim. Any claim intimation to the Company must be made in writing and delivered to the address, which is currently: Claims Unit\nCanara HSBC Oriental Bank of Commerce Life Insurance Company Limited, 2nd Floor, Orchid Business Park , Sector-48, Sohna Road, Gurugram 122018, Haryana, India Resolution Centre: 1800-103-0003 / 1800-180-0003 (BSNL/MTNL) Email id: claims.unit@canarahsbclife.in Any change in the","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"address","value":"Canara HSBC Life Insurance Company Limited, 139 P, Sector 44, Gurugram 122003, Haryana, India","label":"Claims Unit Address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.canarahsbclife.com/content/dam/chli/pdf/product-closed-for-sale/group-products/pmjjby_masterpolicycontract_new1.pdf","quote":"Dear Sir/Madam,\nThank you for choosing Canara HSBC Life Insurance Company Limited as your preferred Insurance partner to provide PMJJBY Scheme to your customers.\nWe are pleased to enclose your Policy Pack for our PMJJBY Plan bearing MASTER POLICY NO. <","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"claims.unit@canarahsbclife.in","label":"Claims Unit Email","level":null,"hours":null,"applies_to":"all","source_url":"https://irdai.gov.in/documents/37343/563751/136G046V01_2017-18.pdf/f050bed9-5535-1986-8392-ad04d16ecd43?version=1.1&t=1667553755436&download=true","quote":"-48, Sohna Road, Gurugram 122018, Haryana, India Resolution Centre: 1800-103-0003 / 1800-180-0003 (BSNL/MTNL) Email id: claims.unit@canarahsbclife.in Any change in the address or details above will be communicated by the Company to the Master Policyholder in writing.\nF","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-103-0003 / 1800-180-0003 (BSNL/MTNL)","label":"Resolution Centre","level":null,"hours":null,"applies_to":"all","source_url":"https://irdai.gov.in/documents/37343/563751/136G046V01_2017-18.pdf/f050bed9-5535-1986-8392-ad04d16ecd43?version=1.1&t=1667553755436&download=true","quote":"ny Limited, 2nd Floor, Orchid Business Park , Sector-48, Sohna Road, Gurugram 122018, Haryana, India Resolution Centre: 1800-103-0003 / 1800-180-0003 (BSNL/MTNL) Email id: claims.unit@canarahsbclife.in Any change in the address or details above will be communicated by the Company","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-103-0003 / 1800-180-0003 /1800-891-0003","label":"Resolution Centre","level":null,"hours":null,"applies_to":"all","source_url":"https://www.canarahsbclife.com/content/dam/chli/pdf/product-closed-for-sale/group-products/pmjjby_masterpolicycontract_new1.pdf","quote":"6V01)\n\nCanara HSBC Life Insurance Company Limited, 139 P, Sector 44, Gurugram 122003, Haryana, India Resolution Centre: 1800-103-0003 / 1800-180-0003 /1800-891-0003\nEmail id: claims.unit@canarahsbclife.in Any change in the address or details above will be communicated by the Company","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/canara-hsbc-life-insurance/131-physicians-statement"}