{"id":44,"title":"CERTIFICATE OF EMPLOYER - CI CLAIM","purpose":"claim","insurer":{"slug":"bandhan-life-insurance","name":"Bandhan Life Insurance Limited"},"source_pdf":"https://www.bandhanlife.com/sites/default/files/asset/2026-04/Certificate%20of%20Employer%20-%20Critical%20Illness.pdf","sha256":"a56754602c3fb03b9a8b6257830252b971daf3bff1cb3a2ec9900efd2122a4db","pages":1,"collected":"2026-10-17","instructions":{"about":"This form is a certificate to be filled by the employer to provide details about the life assured's employment, medical insurance coverage, and leave history for a critical illness claim.","notes":["Registered office address and contact details are printed at the bottom for reference","Use the employer's signature and company seal where indicated"],"title":"CERTIFICATE OF EMPLOYER - CI CLAIM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section I","fields":[{"help":"","type":"text","label":"Policy No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Life Assured","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of Life Assured","options":[],"required":null,"pdf_field":""},{"help":"Describe the job duties and designation of the life assured","type":"text","label":"Nature of Duties and designation","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of joining the service","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Last day (date) of attending duties","options":[],"required":null,"pdf_field":""}],"filled_by":"employer"},{"title":"Section II","fields":[{"help":"Select Yes or No","type":"choice","label":"Was the Life Assured covered under any medical insurance policy or medical reimbursement scheme - Yes / No.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill the table with Period of illness (From, To), Particulars of illness, Amount Medical Expenses reimbursed","type":"table","label":"If yes, Please provide details of the same and of any disbursements made to the Life Assured by the employer under its medical reimbursement scheme during the past 3 years for each spell of illness","options":[],"required":null,"pdf_field":""}],"filled_by":"employer"},{"title":"Section III","fields":[{"help":"Fill the table with Nature of Leave, Exact reason for availing leave, Period of Illness (From, To), Whether medical certificate Submitted? (Yes/No)","type":"table","label":"Nature and Duration of leave granted to the Insured on each occasion (Please state nature of leave granted i.e. Casual leave, Earned/Privilege leave, Sick leave etc.) during the last three years. If medical certificates were produced in support of the leave applications, please furnish copies of the leave applications and medical certificates.","options":[],"required":null,"pdf_field":""}],"filled_by":"employer"},{"title":"Employer's Declaration","fields":[{"help":"","type":"signature","label":"Signature of Employer","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name & Designation","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Tel. with STD code","options":[],"required":null,"pdf_field":""},{"help":"Affix company seal","type":"signature","label":"Company Seal","options":[],"required":null,"pdf_field":""}],"filled_by":"employer"}],"deadlines":[],"applies_to":"Critical Illness claims","attachments":["Copies of leave applications and medical certificates if medical certificates were produced in support of leave applications"],"declarations":[],"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/44-certificate-of-employer-ci-claim"}