{"id":48,"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_Urdu.pdf","sha256":"99f2dbc382accff855dd9842d7ad150e92cca6cac740b5ca09d60b08753e7cd0","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for claiming accidental disability benefits under a 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.","Use clear and unambiguous information.","Acceptance of forms does not amount to admission of liability by the company.","KYC documents of claimant are mandatory."],"title":"APPLICATION FORM FOR ACCIDENTAL DISABILITY CLAIM CLAIMANTS STATEMENT","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Information about the Claimant","fields":[{"help":"","type":"text","label":"Policy No","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"Include full address and telephone number","type":"text","label":"Complete Address & Tel. No.","options":[],"required":true,"pdf_field":""},{"help":"Telephone number of claimant","type":"phone","label":"Tel. No.","options":[],"required":true,"pdf_field":""},{"help":"Age in completed 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":""},{"help":"Name of the claimant if different","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Age of claimant at time of disability","type":"number","label":"Age (at the time of disability)","options":[],"required":true,"pdf_field":""},{"help":"Date when accident occurred","type":"date","label":"Date of Accident","options":[],"required":true,"pdf_field":""},{"help":"Location where accident happened","type":"text","label":"Place of Accident","options":[],"required":true,"pdf_field":""},{"help":"Time when accident happened","type":"text","label":"Time of Accident","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Information about the Life Assured and Accident","fields":[{"help":"Date of filling this section","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Name of last employer of life assured","type":"text","label":"Last Employer’s name","options":[],"required":false,"pdf_field":""},{"help":"Designation of life assured at last employment","type":"text","label":"Designation","options":[],"required":false,"pdf_field":""},{"help":"Address of last employer","type":"text","label":"Last Employer’s address","options":[],"required":false,"pdf_field":""},{"help":"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":"Name of bank where claimant holds account","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Claimant's bank account number","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Police and Hospital Information","fields":[{"help":"Provide 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":"FIR number","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"Telephone number of police station","type":"phone","label":"Tel. No.","options":[],"required":false,"pdf_field":""},{"help":"Hospital details for treatment","type":"text","label":"Name and address of Hospital (where last/current treatment was/ is conducted)","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Medical History","fields":[{"help":"Indicate if life assured had any recurring health issues","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 ongoing health problems if any","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":"Duration of the illness or ailment","type":"text","label":"Duration of illness/ailment/disorder","options":[],"required":false,"pdf_field":""},{"help":"Doctor or hospital details for treatment of above illness","type":"text","label":"Name of the doctor/hospital where the Life Assured was treated for the same.","options":[],"required":false,"pdf_field":""},{"help":"List 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":""}],"filled_by":"claimant"},{"title":"Other Insurance Policies","fields":[{"help":"Details of other insurance policies held","type":"text","label":"Particulars of other Life Insurance/Mediclaim policies held by the Life Assured","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Additional Information","fields":[{"help":"Provide any other 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 the circumstances of the accident","type":"text","label":"How did the accident occur?","options":[],"required":false,"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":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vernacular Declaration","fields":[{"help":"Name of witness if claimant signs in vernacular or thumb impression","type":"text","label":"Name of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Address of witness","type":"text","label":"Address of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Witness contact number","type":"phone","label":"Contact No. of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Select the category of witness","type":"choice","label":"Witness declaration to be signed by any of these","options":["Person of local standing","Special Executive Magistrate","Notary","Lawyer","Class 1 Gazette Officer"],"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. 60/60","Copy of any one of the following (Identity & address proof of claimant)","One recent photograph of the claimant"],"declarations":["The claimant declares that the statements made are true and understands that submission of the form does not admit liability by the insurer.","The claimant consents to the insurer obtaining all relevant records and conducting investigations as needed.","Payment of claim amount discharges the insurer's liability under the policy.","If claimant signs in vernacular or thumb impression, a witness must sign a declaration confirming the claimant understood the form.","The witness certifies that the form contents were explained to the claimant in vernacular and the claimant signed after understanding."],"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/48-application-form-for-accidental-disability-claim-claimants-statement"}