{"id":45,"title":"ATTENDING PHYSICIAN'S STATEMENT FOR DEATH CLAIMS","purpose":"claim","insurer":{"slug":"bandhan-life-insurance","name":"Bandhan Life Insurance Limited"},"source_pdf":"https://www.bandhanlife.com/sites/default/files/asset/2026-04/Attending%20physicians%20Statement%20-%20Death%20Claim.pdf","sha256":"95bbf1628ff2f1352611f74f9a902854ccf9d854cb9eaf24c5f3aeb10b107cfe","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is to be completed by the medical attendant (a qualified and registered physician) of the deceased during the last illness to provide medical details for a death claim under an insurance policy.","notes":["A qualified and registered physician must complete this form.","Attach separate sheets if required.","Fill the form based on medical records maintained by the doctor."],"title":"ATTENDING PHYSICIAN'S STATEMENT FOR DEATH CLAIMS","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Deceased Details and Medical History","fields":[{"help":"Enter the insurance policy number related to the claim.","type":"text","label":"Claim under Policy Number :","options":[],"required":null,"pdf_field":""},{"help":"Provide full name, address, and occupation of the deceased.","type":"text","label":"Full name, address & occupation of the deceased :","options":[],"required":null,"pdf_field":""},{"help":"Full name of the deceased.","type":"text","label":"Name :","options":[],"required":null,"pdf_field":""},{"help":"Residential address of the deceased.","type":"text","label":"Address :","options":[],"required":null,"pdf_field":""},{"help":"Occupation of the deceased.","type":"text","label":"Occupation :","options":[],"required":null,"pdf_field":""},{"help":"Age in years at time of death.","type":"number","label":"a) Age of Life Assured at the time of death :","options":[],"required":null,"pdf_field":""},{"help":"Specify relationship to the deceased if any.","type":"text","label":"Was he/she related to you? If so, How? :","options":[],"required":null,"pdf_field":""},{"help":"Duration of acquaintance with the deceased.","type":"text","label":"How long had you known the deceased? :","options":[],"required":null,"pdf_field":""},{"help":"Specify time of death with AM or PM.","type":"text","label":"a) Time of death : - a.m. / p.m.","options":["a.m.","p.m."],"required":null,"pdf_field":""},{"help":"Date when the deceased passed away.","type":"date","label":"Date of death :","options":[],"required":null,"pdf_field":""},{"help":"Location where death occurred.","type":"text","label":"Place of death :","options":[],"required":null,"pdf_field":""},{"help":"Describe the immediate cause of death.","type":"text","label":"a) What was the immediate cause of death? :","options":[],"required":null,"pdf_field":""},{"help":"List symptoms experienced by the deceased.","type":"text","label":"What were the exact complaints/ symptoms? :","options":[],"required":null,"pdf_field":""},{"help":"Duration of illness before death.","type":"text","label":"How long had he/she been suffering from this disease before death?","options":[],"required":null,"pdf_field":""},{"help":"Date of first consultation for last illness.","type":"date","label":"What was the date on which you were first consulted for the last illness? :","options":[],"required":null,"pdf_field":""},{"help":"Date of last consultation or follow-up.","type":"date","label":"What was the date of last consultation/follow up? :","options":[],"required":null,"pdf_field":""},{"help":"Duration of being the usual doctor if applicable.","type":"text","label":"Were you the deceased's usual doctor? If yes, please state: - For how long :","options":[],"required":null,"pdf_field":""},{"help":"List dates of consultations.","type":"table","label":"Date(s) of Consultation : 1) 2)","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment provided.","type":"text","label":"Treatment given :","options":[],"required":null,"pdf_field":""},{"help":"Provide details and dates of medical care and complaints.","type":"text","label":"Since when was the deceased under any kind Date of medical care. What were the complaints Details","options":[],"required":null,"pdf_field":""},{"help":"Details of past and last illness treatment.","type":"text","label":"Please give details of treatment rendered in the past and for last illness","options":[],"required":null,"pdf_field":""},{"help":"List investigations and tests done to confirm diagnosis.","type":"text","label":"Please provide details of the investigations conducted and tests undergone so as to confirm the diagnosis (attach separate sheets if required)","options":[],"required":null,"pdf_field":""},{"help":"Date of final diagnosis.","type":"date","label":"a) When was the final diagnosis made? :","options":[],"required":null,"pdf_field":""},{"help":"Duration since the deceased suffered from the ailment.","type":"text","label":"b) Since when did the deceased suffer from this ailment? :","options":[],"required":null,"pdf_field":""}],"filled_by":"medical attendant"},{"title":"Additional Medical Information","fields":[{"help":"Details of any antecedent illnesses.","type":"text","label":"Did the deceased suffer from any antecedent illness?? If yes please give the details (attach separate sheets if required)","options":[],"required":null,"pdf_field":""},{"help":"Indicate if post mortem was done and cause of death per report.","type":"text","label":"Was any Post Mortem Examination conducted? : If yes, Please give the cause death as per the Post Mortem Report","options":[],"required":null,"pdf_field":""},{"help":"Any other relevant information about the deceased.","type":"text","label":"Have you any other information/ to be shared with us in connection with this claim concerning deceased's s, habits etc. :","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other doctors who attended the deceased in last 3 years.","type":"table","label":"Can you give names of the other Medical practitioners who had attended the deceased during the last 3-years? Name of the Doctor, Address, Contact No, Date of Consultation, Diagnosis arrived at","options":[],"required":null,"pdf_field":""}],"filled_by":"medical attendant"},{"title":"Declaration and Signature","fields":[{"help":"Date and place of signing.","type":"date","label":"Dated at this day of ______________________________ 20","options":[],"required":null,"pdf_field":""},{"help":"Full name of the medical attendant.","type":"text","label":"Name of Medical Attendant :","options":[],"required":true,"pdf_field":""},{"help":"Medical qualifications of the attendant.","type":"text","label":"Qualification(s) :","options":[],"required":true,"pdf_field":""},{"help":"Postal address of the medical attendant.","type":"text","label":"Postal Address :","options":[],"required":true,"pdf_field":""},{"help":"Official stamp of the medical attendant.","type":"signature","label":"Stamp of Medical Attendant :","options":[],"required":true,"pdf_field":""},{"help":"Signature of the medical attendant.","type":"signature","label":"Signature of Medical Attendant :","options":[],"required":true,"pdf_field":""},{"help":"Contact telephone number including STD code.","type":"phone","label":"Telephone number (with STD Code) :","options":[],"required":null,"pdf_field":""}],"filled_by":"medical attendant"}],"deadlines":[],"applies_to":"death claims","attachments":["Separate sheets if required for additional information","Investigations and tests reports","Post Mortem Report if conducted"],"declarations":["The medical attendant declares that the statements are based on records maintained in the normal course of profession."],"dropped_labels":2},"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/45-attending-physician-s-statement-for-death-claims"}