{"id":2311,"title":"Domiciliary Treatment Benefit Claim Discharge Form","purpose":"claim","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/dtb_discharge_form_insurance-1-","sha256":"6e6dbee315f8d2ce00597c330f1f76f48f09dcd972917b2ec1938ec6665eda10","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is for the policyholder to authorize payment of the Domiciliary Treatment Benefit (DTB) claim and to provide bank details for payment transfer.","notes":["Issuance of this Claim Form does not tantamount to acceptance of Liability by the Insurer.","Attach original bills and receipts for the DTB claim.","Use the eleven digit IFSC code for NEFT/RTGS payments.","Revenue stamp required on the form."],"title":"Domiciliary Treatment Benefit Claim Discharge Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policyholder Details and Authorization","fields":[{"help":"Enter your policy number","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the principal insured","type":"text","label":"Name of the Principal Insured:","options":[],"required":null,"pdf_field":""},{"help":"Select the preferred payment mode","type":"choice","label":"Option to be provided by the Policyholder for DTB Claim payment to be made by NEFT/RTGS or Demand Draft","options":["ELECTRONIC MODE OF TRANFER","Demand Draft"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Bank Account Details for Payment Transfer","fields":[{"help":"Enter the name of your bank","type":"text","label":"NAME OF THE BANK","options":[],"required":null,"pdf_field":""},{"help":"Enter the location of your bank branch","type":"text","label":"Location","options":[],"required":null,"pdf_field":""},{"help":"Enter the branch code of your bank","type":"text","label":"Branch Code","options":[],"required":null,"pdf_field":""},{"help":"Enter your bank account number","type":"text","label":"A/C NO","options":[],"required":null,"pdf_field":""},{"help":"Enter the 11-digit IFSC code for NEFT/RTGS payments","type":"text","label":"IFSC NO","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declaration and Signature","fields":[{"help":"Enter the place where you are signing","type":"text","label":"DATED AT","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of signing","type":"date","label":"THIS ____ DAY OF ____ 200__","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"SIGNATURE OF THE POLICYHOLDER/ CLAIMANT","options":[],"required":true,"pdf_field":""},{"help":"Enter your full name and address","type":"text","label":"Name and Address of the Claimant","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":[],"applies_to":"Domiciliary Treatment Benefit (DTB) claims","attachments":["bills, receipts, etc submitted for the DTB claim"],"declarations":["I authorize Life Insurance Corporation of India to make payment of DTB as per policy terms.","This discharge is full and final settlement of the DTB claim on the submitted bills and receipts.","The bank account details provided are correct and I authorize payment to be made to this account."],"dropped_labels":0},"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/lic/2311-domiciliary-treatment-benefit-claim-discharge-form"}