{"id":49,"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_Telugu.pdf","sha256":"047daf7cc36854162afb05bde143902213adf091cc6fe05cd6e2c0927adebfb0","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' are mandatory.","The claimant must be the holder of the bank account provided.","Attach original documents as per the checklist.","Acceptance of forms does not amount to admission of liability by the company.","If the claimant signs in vernacular or with thumb impression, a witness must sign the vernacular declaration.","Use clear and unambiguous details."],"title":"APPLICATION FORM FOR ACCIDENTAL DISABILITY CLAIM CLAIMANTS STATEMENT","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Information about the Claimant","fields":[{"help":"Enter the policy number(s) related to the claim","type":"text","label":"Policy No/ పాలసీ నంబర(లు)","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of the claimant","type":"text","label":"Name of the Claimant/ దావేదారుడి పేరు","options":[],"required":true,"pdf_field":""},{"help":"Provide full postal address and telephone number","type":"text","label":"Complete Address & Tel. No./ పూరిƕ చిరునామా & ఫోన నంబర","options":[],"required":true,"pdf_field":""},{"help":"Primary telephone number","type":"phone","label":"Tel. No. / ఫోన నంబర 1)","options":[],"required":true,"pdf_field":""},{"help":"Enter age in completed years","type":"number","label":"Age of Claimant/ దావేదారుడి వయసు In Years/ సంవతƧరాలలో","options":[],"required":true,"pdf_field":""},{"help":"Select the claimant's relationship to the deceased and specify if 'Others'","type":"choice","label":"Relationship of the Claimant to the Deceased/ దావేదారు మరణించిన వƟకిƕ కి ఉనƙ బంధం","options":["Parent/ తలిƢ దండుƠ లు","Spouse/ భారƟ /భరƕ","Son/ Daughter/ కొడుకు/కూతురు","Others (Specify)/ ఇతరులు (వివరించండి)"],"required":true,"pdf_field":""},{"help":"If 'Others' selected above, specify the relationship name","type":"text","label":"Name/ పేరు","options":[],"required":false,"pdf_field":""},{"help":"Enter age of the life assured at the time of disability","type":"number","label":"Age (at the time of disability)/ వయసుƧ (వైకలƟం సమయంలో)","options":[],"required":true,"pdf_field":""},{"help":"Enter the date when the accident occurred","type":"date","label":"Date of Accident/ పƠ మాదం జరిగిన తేదీ","options":[],"required":true,"pdf_field":""},{"help":"Enter the location of the accident","type":"text","label":"Place of Accident/ పƠ మాదం జరిగిన సƖ లం","options":[],"required":true,"pdf_field":""},{"help":"Enter the time of the accident if known","type":"text","label":"Time of Accident/ సమయం","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Information about the Life Assured and Accident","fields":[{"help":"Date of filling or relevant date","type":"date","label":"Date/ తేదీ","options":[],"required":false,"pdf_field":""},{"help":"Name of the last employer of the life assured","type":"text","label":"Last Employer’s name/ యజమాని ఇంటి పేరు","options":[],"required":false,"pdf_field":""},{"help":"Designation of the life assured at last employment","type":"text","label":"Designation/ పదవి","options":[],"required":false,"pdf_field":""},{"help":"Address of the last employer","type":"text","label":"Last Employer’s address/ చివరి యజమాని చిరునామా","options":[],"required":false,"pdf_field":""},{"help":"Last residential address of the life assured","type":"text","label":"Last residential address/ చివరి నివాస చిరునామా","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details","fields":[{"help":"Name of the bank where claimant holds account","type":"text","label":"Bank Name/ బాƟంక పేరు","options":[],"required":true,"pdf_field":""},{"help":"Bank account number of the claimant","type":"text","label":"Bank Account No./ బాƟంక ఖాతా నంబర","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Police and Hospital Information","fields":[{"help":"Provide police station details where FIR was filed and attach FIR copy","type":"text","label":"Name and address of Police Station where FIR was lodged (Please furnish a copy of the FIR)/ ఎఫ ఐఆర నమోదైన పోలీస సేƐ షన పేరు మరియు చిరునామా (దయచేసి ఎఫ ఐఆర కాపీ జోడించండి)","options":[],"required":false,"pdf_field":""},{"help":"Enter FIR number","type":"text","label":"FIR No./ ఎఫ ఐఆర నంబర","options":[],"required":false,"pdf_field":""},{"help":"Phone number of the police station","type":"phone","label":"Tel. No./ ఫోన నంబర","options":[],"required":false,"pdf_field":""},{"help":"Provide hospital name and address where treatment was given","type":"text","label":"Name and address of Hospital (where last/current treatment was/ is conducted)/ ఆసుపతిƠ పేరు మరియు చిరునామా (చివరి / పƠ సుƕ తం చికితƧ పొందినది)","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Health and Medical History","fields":[{"help":"Indicate if the life assured had any ongoing health issues","type":"yes-no","label":"Did the Life Assured suffer from any ongoing recurrent health problems?/ లైఫ అషూƟరƒ్ కు ఎలాంటి కొనసాగుతునƙ ఆరోగƟ సమసƟలునాƙయా?","options":["Yes / అవును","No / కాదు"],"required":false,"pdf_field":""},{"help":"Provide details of illness if answered Yes above","type":"text","label":"If yes, please furnish the details below./ అవునని అయితే, కింది వివరాలను ఇవƤండి.","options":[],"required":false,"pdf_field":""},{"help":"Describe the nature of illness or disorder","type":"text","label":"Nature of illness/ailment/disorder / వాƟధి / అనారోగƟం / లోపం సƤభావం","options":[],"required":false,"pdf_field":""},{"help":"Duration of the illness or disorder","type":"text","label":"Duration of illness/ailment/disorder / అనారోగƟం వƟవధి","options":[],"required":false,"pdf_field":""},{"help":"Name of doctor or hospital where treatment was received","type":"text","label":"Name of the doctor/hospital where the Life Assured was treated for the same./ చికితƧ చేసిన డాకƐ ర/ఆసుపతిƠ పేరు","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 / గత మూడు సంవత్సరాలలో చికిత్స చేసిన డాక్టర్లు / ఆసుపతులు పేరు మరియు చిరునామాలు మరియు చేసిన చికిత్స వివరాలు","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Other Insurance and Additional Information","fields":[{"help":"List other insurance or mediclaim policies held by the life assured","type":"text","label":"Particulars of other Life Insurance/Mediclaim policies held by the Life Assured/ లైఫ అషూƟరƒ్ కి ఉనƙ ఇతర లైఫ ఇనూƧరెనƧ్ / మెడికెƢ యిమ పాలసీల వివరాలు","options":[],"required":false,"pdf_field":""},{"help":"Provide any other relevant information for claim processing","type":"text","label":"Any other information, which you consider, would be vital in the claim review process under this policy?/ ఈ పాలసీ పƠ కారం కెƢ యిమ సమీక̀లో ఉపయోగపడే అదనపు సమాచారం ఏదైనా ఉందా?","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?/ పƠ మాదం ఎలా జరిగింది?","options":[],"required":true,"pdf_field":""},{"help":"List people involved in the accident","type":"text","label":"People involved in the accident/ పƠ మాదంలో పాలొƇ న్క వƟకుƕ లు","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration & Authorization","fields":[{"help":"Sign to declare the truthfulness of the statements and authorize the insurer to obtain records","type":"signature","label":"Declaration & Authorization / పƟ కటన మరియు అనుమతి","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Claimant / దావేదారుడి సంతకం","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date/ తేదీ","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place/ సƖ లం","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vernacular Declaration","fields":[{"help":"Name of the witness who explained the form in vernacular","type":"text","label":"Name of the Witness/ సాకి̀ పేరు","options":[],"required":true,"pdf_field":""},{"help":"Address of the witness","type":"text","label":"Address of the Witness/ చిరునామా","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of the Witness / సాకి̀ యొకƅ సంతకం","options":[],"required":true,"pdf_field":""},{"help":"Phone number of the witness","type":"phone","label":"Contact No. of the Witness/ సాకి̀ యొకƅ ఫోన నంబర","options":[],"required":true,"pdf_field":""}],"filled_by":"witness"}],"deadlines":[],"applies_to":"Accidental disability claims under 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)","KYC documents of claimant","One recent photograph of the claimant"],"declarations":["The claimant declares that the statements made are true and that submitting this form does not admit insurance or waive rights.","The claimant consents to Bandhan Life Insurance Ltd obtaining all relevant records and conducting investigations.","Payment of claim amount discharges Bandhan Life Insurance Ltd from further liability."],"dropped_labels":1},"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/49-application-form-for-accidental-disability-claim-claimants-statement"}