{"id":347,"title":"Treating Doctor’s Certificate – Critical Illness","purpose":"claim","insurer":{"slug":"indiafirst-life-insurance","name":"IndiaFirst Life Insurance Company Limited"},"source_pdf":"https://www.indiafirstlife.com/content/dam/ifliwebsite/in/en/download-center/claims/treating-doctors-certificate-critical-illness-individual.pdf","sha256":"c4206bf4bb3ab8de414489dff7910beb3de347ac188aa83e80efba0a6fff6049","pages":1,"collected":"2026-10-17","instructions":{"about":"This form is to be completed by the treating doctor to certify the critical illness of the life assured for claim purposes.","notes":["To be completed in BLOCK letters by duly qualified registered medical practitioner at claimant's expense.","Please refer to the policy document for the definition of Terminal Illness."],"title":"Treating Doctor’s Certificate – Critical Illness","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Personal Details of Life Assured","fields":[{"help":"","type":"text","label":"Full Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy number","options":[],"required":null,"pdf_field":""},{"help":"Use date format as per form instructions","type":"date","label":"Date of birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Patient","options":[],"required":null,"pdf_field":""},{"help":"Describe symptoms and how long they have lasted","type":"text","label":"Presenting complaints of illness / disease (With duration)","options":[],"required":null,"pdf_field":""},{"help":"Provide the conclusive medical diagnosis","type":"text","label":"Final diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Include any previous illnesses and their durations","type":"text","label":"Past Medical History (Related / Unrelated with current illness along with duration)","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of First consultation / Admission","options":[],"required":null,"pdf_field":""},{"help":"Specify quantity and duration of habits","type":"text","label":"Habits such as Drinking, Smoking (quantity & duration)","options":[],"required":null,"pdf_field":""},{"help":"Select who provided the medical history","type":"text","label":"History Provided by (Patient himself/ family member / other) Please specify","options":["Patient himself","family member","other"],"required":null,"pdf_field":""},{"help":"Describe treatment administered","type":"text","label":"Treatment Given","options":[],"required":null,"pdf_field":""},{"help":"Fill only if patient was hospitalized","type":"date","label":"Date of Admission (If Hospitalised)","options":[],"required":false,"pdf_field":""},{"help":"Fill only if patient was hospitalized","type":"date","label":"Date of Discharge (If Hospitalised)","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Has the patient ever suffered with this or any similar condition before the present episode?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if patient had similar illness before","type":"text","label":"Details of Illness/Ailment","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"Treating Doctor’s Certificate","fields":[{"help":"Fill only if illness is due to accident","type":"date","label":"Date of Accident","options":[],"required":false,"pdf_field":""},{"help":"Fill only if illness is due to accident","type":"text","label":"FIR/ Case No","options":[],"required":false,"pdf_field":""},{"help":"Fill only if illness is due to accident","type":"text","label":"Place of Accident","options":[],"required":false,"pdf_field":""},{"help":"Tick the relevant type or specify if other","type":"choice","label":"Type of Accident","options":["Road accident","Accident at home","Accident at work","In case of other, please specify"],"required":false,"pdf_field":""},{"help":"Describe the circumstances of the accident","type":"text","label":"How did the accident occur?","options":[],"required":false,"pdf_field":""},{"help":"Tick the relevant option(s)","type":"checkbox","label":"In case of physical severance of Limbs please select relevant details","options":[],"required":false,"pdf_field":""},{"help":"Tick the relevant option(s)","type":"checkbox","label":"In case of loss of sight in eyes please select relevant details","options":[],"required":false,"pdf_field":""},{"help":"Specify treatment period dates","type":"date","label":"Dates - From / To","options":[],"required":false,"pdf_field":""},{"help":"Select patient type during treatment","type":"choice","label":"In Patient / Out Patient","options":["In Patient","Out Patient"],"required":null,"pdf_field":""},{"help":"Explain why treatment was needed","type":"text","label":"Reason for medical treatment","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment provided","type":"text","label":"Treatment Given","options":[],"required":null,"pdf_field":""},{"help":"State the diagnosis made during treatment","type":"text","label":"Diagnosis Made","options":[],"required":null,"pdf_field":""},{"help":"Provide details if patient had previous treatments or admissions","type":"text","label":"Previous treatment, hospitalizations, Surgery or admission details (If ‘YES’ kindly provide us the details)","options":[],"required":null,"pdf_field":""},{"help":"Full name of the treating doctor","type":"text","label":"Name of Doctor","options":[],"required":true,"pdf_field":""},{"help":"Doctor's contact phone number","type":"phone","label":"Contact Numbers","options":[],"required":true,"pdf_field":""},{"help":"Date of certificate completion","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Full hospital name and address","type":"text","label":"Name & Address of Hospital","options":[],"required":true,"pdf_field":""},{"help":"Doctor's signature and official seal","type":"signature","label":"Signature & Seal of Treating Doctor","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"Nature of Illness Suffered","fields":[{"help":"Tick all applicable illnesses; specify if 'Other'","type":"checkbox","label":"Nature of Illness Suffered (Please tick the relevant illness suffered by Life Assured)","options":["Heart attack","Major Organ or Bone Marrow Transplant  (as recipient)","Open Heart Replacement or Repair of Heart Valves","Motor Neurone Disease with Permanent Symptoms","Stroke resulting in Permanent Symptoms","Kidney Failure requiring regular dialysis","Coma with Severity","Open Chest CABG (Coronary Artery Bypass Graft Surgery)","Cancer","Alzheimer’s Disease","Permanent Paralysis of limbs","Parkinson’s","Terminal Illness*","Any other form of Dementia","Other (Please Specify)"],"required":true,"pdf_field":""}],"filled_by":"treating doctor"}],"deadlines":[],"applies_to":"critical illness claims under life insurance policies","attachments":[],"declarations":["The doctor declares that they attended the life insured during the last illness and that the information provided is true to the best of their knowledge."],"dropped_labels":6},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"IndiaFirst Life Insurance Company Ltd., 12th and 13th Floor, North [C] wing, Tower 4, Nesco IT Park, Nesco Center, Western Express Highway, Goregaon (East), Mumbai – 400063","label":"Claims documents submission address","level":null,"hours":null,"applies_to":"life","source_url":"https://www.indiafirstlife.com/claims/claims-overview","quote":"ntative will reach out to you soon to guide you through our life insurance plans that fit your life goals\nHome\nClaims - IndiaFirst Life Insurance\nClaims Overview\nLife Insurance Claim Process\nAt IndiaFirst Life, we stand firmly with our customers in their hour of grief. We provide a streamlined claim registration and settlement process, ensuring a worry-free future for our customers. With a focus on efficiency","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"claims.support@indiafirstlife.com","label":"Claims support email","level":null,"hours":null,"applies_to":"life","source_url":"https://www.indiafirstlife.com/claims/claims-overview","quote":"rstlife.com/claims/claims-overview/register-claim-online\n\"\nEmail:\nShare soft copies of all the mandatory documents at '\nclaims.support@indiafirstlife.com\n'\nCall:\nContact us at 1800-209-8700 for assistance. Our representative will guide you through the claim process registr","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-209-8700","label":"Claims assistance phone","level":null,"hours":null,"applies_to":"life","source_url":"https://www.indiafirstlife.com/claims/claims-overview","quote":"\"\nEmail:\nShare soft copies of all the mandatory documents at '\nclaims.support@indiafirstlife.com\n'\nCall:\nContact us at 1800-209-8700 for assistance. Our representative will guide you through the claim process registration.\nVisit Us:\nDrop soft/hard copi","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"url","value":"https://www.indiafirstlife.com/claims/claims-overview/register-claim-online","label":"Register your claim online","level":null,"hours":null,"applies_to":"life","source_url":"https://www.indiafirstlife.com/claims/claims-overview","quote":"Claim Process\nClaim Documents\nFAQs for Claim\nStep 1. Claim Registration\nAnswer\nOnline:\nRegister your claim online at \"\nhttps://www.indiafirstlife.com/claims/claims-overview/register-claim-online\n\"\nEmail:\nShare soft copies of all the mandatory documents at '\nclaims.support@indiafirstlife.com\n'\nCall:\nContact us at","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/indiafirst-life-insurance/347-treating-doctors-certificate-critical-illness"}