{"id":42,"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_Tamil.pdf","sha256":"5c80f1de7534302e24ec68d7f85d5a3e4d83e0aeaac0ff5c3dc72bdf83b9ee4e","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 be the holder of the bank account provided.","Attach original documents as per the checklist.","If signing in vernacular or thumb impression, a witness must sign the vernacular declaration.","Acceptance of forms does not amount to admission of liability by the company.","Payments will be made according to policy terms and conditions; company may call for further evidence."],"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 insurance 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 if different from above","type":"phone","label":"Tel. No.","options":[],"required":false,"pdf_field":""},{"help":"Enter claimant's age in years","type":"number","label":"Age of Claimant (In Years)","options":[],"required":true,"pdf_field":""},{"help":"Select the claimant's relationship to the deceased","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 of life assured 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 where accident happened","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 relevant date","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Enter name of last employer","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 address of last employer","type":"text","label":"Last Employer’s address","options":[],"required":false,"pdf_field":""},{"help":"Enter 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":"Enter name of bank where claimant holds account","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number of claimant","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Police and Hospital Details","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":false,"pdf_field":""},{"help":"Enter FIR number","type":"text","label":"FIR No.","options":[],"required":false,"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":""}],"filled_by":"claimant"},{"title":"Health and Medical 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":false,"pdf_field":""},{"help":"Provide details of illness/ailment/disorder","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":"Specify 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 details of 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":""},{"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":""}],"filled_by":"claimant"},{"title":"Details of disability/Dismemberment","fields":[{"help":"Describe how the accident happened","type":"text","label":"How did the accident occur?","options":[],"required":false,"pdf_field":""},{"help":"List people 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 here","type":"signature","label":"Signature of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Enter witness phone number","type":"phone","label":"Contact No. of the Witness","options":[],"required":true,"pdf_field":""}],"filled_by":"witness"}],"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 (Identity & address proof of claimant)","KYC documents of claimant","One recent photograph of the claimant"],"declarations":["The claimant declares that all statements are true and understands that submitting 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.","Payment of claim amount discharges Bandhan Life Insurance Ltd from further liability."],"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/42-application-form-for-accidental-disability-claim-claimants-statement"}