{"id":34,"title":"APPLICATION FORM FOR ACCIDENTAL DISABILITY CLAIM CLAIMANTS STATEMENT","purpose":"claim","insurer":{"slug":"bandhan-life-insurance","name":"Bandhan Life Insurance Limited"},"source_pdf":"https://www.bandhanlife.com/sites/default/files/asset/2026-04/Accidental%20Disability_Claim%20Form_Bengali.pdf","sha256":"912b0ae3a5037b6e19e4934c9478d28c6587156417a06aba8c6d32d2f62bf373","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for claiming accidental disability benefits under a Bandhan Life insurance policy. It is filled by the claimant who is legally entitled to the policy money.","notes":["All fields under 'Information about the Claimant' and 'Bank Account Details' are mandatory.","The claimant must hold the bank account in their own name.","Attach original or valid copies of all required documents.","Acceptance of the form does not mean acceptance of the claim by the company.","Use clear and unambiguous information."],"title":"APPLICATION FORM FOR ACCIDENTAL DISABILITY CLAIM CLAIMANTS STATEMENT","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Information about the Claimant","fields":[{"help":"Enter your policy number","type":"text","label":"Policy No","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of the claimant","type":"text","label":"Name of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"Enter full address and telephone number","type":"text","label":"Complete Address & Tel. No.","options":[],"required":true,"pdf_field":""},{"help":"Enter telephone number","type":"phone","label":"Tel. No.","options":[],"required":false,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age of Claimant In Years","options":[],"required":true,"pdf_field":""},{"help":"Select relationship and specify if Others","type":"choice","label":"Relationship of the Claimant to the Deceased","options":["Parent","Spouse","Son/ Daughter","Others (Specify)"],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Information about the Life Assured and Accident","fields":[{"help":"Name of the life assured","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Age of life assured at disability","type":"number","label":"Age (at the time of disability)","options":[],"required":true,"pdf_field":""},{"help":"Date when accident occurred","type":"date","label":"Date of Accident","options":[],"required":true,"pdf_field":""},{"help":"Location of accident","type":"text","label":"Place of Accident","options":[],"required":true,"pdf_field":""},{"help":"Time when accident occurred","type":"text","label":"Time of Accident","options":[],"required":true,"pdf_field":""},{"help":"Date of form filling","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Name of last employer","type":"text","label":"Last Employer’s name","options":[],"required":false,"pdf_field":""},{"help":"Designation at last employment","type":"text","label":"Designation","options":[],"required":false,"pdf_field":""},{"help":"Address of last employer","type":"text","label":"Last Employer’s address","options":[],"required":false,"pdf_field":""},{"help":"Last residential address of life assured","type":"text","label":"Last residential address","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details","fields":[{"help":"Name of bank where claimant holds account","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Claimant's bank account number","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Police and Hospital Information","fields":[{"help":"Provide police station details and attach FIR copy","type":"text","label":"Name and address of Police Station where FIR was lodged (Please furnish a copy of the FIR)","options":[],"required":true,"pdf_field":""},{"help":"FIR number","type":"text","label":"FIR No.","options":[],"required":true,"pdf_field":""},{"help":"Police station telephone number","type":"phone","label":"Tel. No.","options":[],"required":false,"pdf_field":""},{"help":"Hospital details where treatment was given","type":"text","label":"Name and address of Hospital (where last/current treatment was/ is conducted)","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Health History","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Did the Life Assured suffer from any ongoing recurrent health problems?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe nature and duration of illness and treatment details","type":"text","label":"If yes, please furnish the details below.","options":[],"required":false,"pdf_field":""},{"help":"Specify illness or disorder","type":"text","label":"Nature of illness/ailment/disorder","options":[],"required":false,"pdf_field":""},{"help":"Duration of illness","type":"text","label":"Duration of illness/ailment/disorder","options":[],"required":false,"pdf_field":""},{"help":"Doctor or hospital name for treatment","type":"text","label":"Name of the doctor/hospital where the Life Assured was treated for the same.","options":[],"required":false,"pdf_field":""},{"help":"List doctors/hospitals and ailments treated in last 3 years","type":"text","label":"Name & Addresses of the Doctor/ Hospital(s) who treated him/her during the last three years & the ailments treated by them","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Other Insurance and Additional Information","fields":[{"help":"Details of other insurance policies","type":"text","label":"Particulars of other Life Insurance/Mediclaim policies held by the Life Assured","options":[],"required":false,"pdf_field":""},{"help":"Provide any other relevant information","type":"text","label":"Any other information, which you consider, would be vital in the claim review process under this policy?","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of disability/Dismemberment","fields":[{"help":"Describe the accident circumstances","type":"text","label":"How did the accident occur?","options":[],"required":true,"pdf_field":""},{"help":"List persons involved in the accident","type":"text","label":"People involved in the accident","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration & Authorization","fields":[{"help":"Sign the form","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vernacular Declaration","fields":[{"help":"Name of witness if claimant signs in vernacular or thumb impression","type":"text","label":"Name of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Address of witness","type":"text","label":"Address of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Witness contact number","type":"phone","label":"Contact No. of the Witness","options":[],"required":true,"pdf_field":""}],"filled_by":"witness"},{"title":"Document Checklist","fields":[{"help":"Attach medical attendant certificate","type":"attachment","label":"Medical Attendant Certificate","options":[],"required":true,"pdf_field":""},{"help":"Attach police report","type":"attachment","label":"Police report for accident claims","options":[],"required":true,"pdf_field":""},{"help":"Attach Aadhaar card copy","type":"attachment","label":"Proof of possession of Aadhaar number in such form as are issued by the Unique Identification Authority of India (means 'Aadhaar Card')","options":[],"required":true,"pdf_field":""},{"help":"Attach PAN card or Form 60","type":"attachment","label":"PAN or Form No. 60","options":[],"required":true,"pdf_field":""},{"help":"Attach one valid ID proof","type":"attachment","label":"Copy of any one of the following (Identity & address proof of claimant)","options":["Valid Passport","Valid Driving License","Voter's Identity Card","Job card issued by NREGA duly signed by an officer of the State Government"],"required":true,"pdf_field":""},{"help":"Attach KYC documents","type":"attachment","label":"KYC documents of claimant (Mandatory)","options":[],"required":true,"pdf_field":""},{"help":"Attach recent photo","type":"photo","label":"One recent photograph of the claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Accidental disability claims","attachments":["Copy of the FIR","Medical Attendant Certificate","Police report for accident claims","Proof of possession of Aadhaar number (Aadhaar Card)","PAN or Form No. 60","Copy of any one of the following: Valid Passport, Valid Driving License, Voter's Identity Card, Job card issued by NREGA duly signed by an officer of the State Government","KYC documents of claimant","One recent photograph of the claimant"],"declarations":["The claimant declares that all statements are true and understands that submission of this form does not admit insurance liability or waive any rights.","The claimant consents to Bandhan Life Insurance Ltd and its representatives obtaining all relevant records and conducting investigations as needed.","Payment of claim amount will discharge Bandhan Life Insurance Ltd of its liability.","If claimant signs in vernacular or thumb impression, a witness must certify that the form contents were explained and understood."],"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/34-application-form-for-accidental-disability-claim-claimants-statement"}