{"id":38,"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_Oriya.pdf","sha256":"d13adc362c940240e3f20f7ce6a434f921233ca36404c8463dcc197575c12c4e","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for claiming accidental disability benefits under a life insurance policy and is to be filled by the claimant who is legally entitled to the policy money.","notes":["All fields under 'Information about the Claimant' and 'Bank Account Details' sections are mandatory.","The claimant must be the holder of the bank account provided.","Use clear and unambiguous details.","Attach original or valid copies of required documents.","Payments will be made as per policy terms and conditions.","The company reserves the right to call for further evidence to process the claim.","Acceptance of forms does not amount to admission of liability by the company."],"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 postal 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":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age of Claimant In Years","options":[],"required":true,"pdf_field":""},{"help":"Select the 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":"Enter name of the life assured","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter age at time of disability","type":"number","label":"Age (at the time of disability)","options":[],"required":true,"pdf_field":""},{"help":"Enter date when accident occurred","type":"date","label":"Date of Accident","options":[],"required":true,"pdf_field":""},{"help":"Enter location of accident","type":"text","label":"Place of Accident","options":[],"required":true,"pdf_field":""},{"help":"Enter time of accident","type":"text","label":"Time of Accident","options":[],"required":true,"pdf_field":""},{"help":"Enter date of form filling","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Enter last employer's name","type":"text","label":"Last Employer’s name","options":[],"required":false,"pdf_field":""},{"help":"Enter designation at last employment","type":"text","label":"Designation","options":[],"required":false,"pdf_field":""},{"help":"Enter last employer's address","type":"text","label":"Last Employer’s address","options":[],"required":false,"pdf_field":""},{"help":"Enter last residential address","type":"text","label":"Last residential address","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details","fields":[{"help":"Enter name of bank where account is held","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Police and Hospital Information","fields":[{"help":"Enter 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":"Enter FIR number","type":"text","label":"FIR No.","options":[],"required":true,"pdf_field":""},{"help":"Enter police station telephone number","type":"phone","label":"Tel. No.","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital name and address","type":"text","label":"Name and address of Hospital (where last/current treatment was/ is conducted)","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Did the Life Assured suffer from any ongoing recurrent health problems?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details of illness if yes above","type":"text","label":"If yes, please furnish the details below.","options":[],"required":false,"pdf_field":""},{"help":"Describe the illness or disorder","type":"text","label":"Nature of illness/ailment/disorder","options":[],"required":false,"pdf_field":""},{"help":"Enter duration of illness","type":"text","label":"Duration of illness/ailment/disorder","options":[],"required":false,"pdf_field":""},{"help":"Enter 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":"Provide names, addresses 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":""},{"help":"List other insurance policies held","type":"text","label":"Particulars of other Life Insurance/Mediclaim policies held by the Life Assured","options":[],"required":false,"pdf_field":""},{"help":"Provide any additional 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":""},{"help":"Describe the disability or dismemberment","type":"text","label":"Details of disability/Dismemberment","options":[],"required":true,"pdf_field":""},{"help":"Explain the circumstances of the accident","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":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vernacular Declaration (if applicable)","fields":[{"help":"Enter witness name","type":"text","label":"Name of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Enter witness address","type":"text","label":"Address of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Witness must sign","type":"signature","label":"Signature of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Enter witness contact number","type":"phone","label":"Contact No. of the Witness","options":[],"required":true,"pdf_field":""}],"filled_by":"witness"}],"deadlines":[],"applies_to":"Accidental disability claims under Bandhan Life Insurance policies","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 (Identity & address proof of claimant): Valid Passport, Valid Driving License, Voter's Identity Card, Job card issued by NREGA duly signed by an officer of the State Government","One recent photograph of the claimant"],"declarations":["The claimant declares that the statements made are true and correct.","Submission of this form does not constitute admission of insurance or waiver of rights by the company.","Consent is given to Bandhan Life Insurance Ltd and its representatives to obtain all relevant records and conduct investigations.","Payment of claim amount shall discharge the liability of Bandhan Life Insurance Ltd.","If the claimant signs in vernacular or with thumb impression, a witness must sign a declaration confirming explanation of the form contents."],"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/38-application-form-for-accidental-disability-claim-claimants-statement"}