{"id":50,"title":"Affinity-Group Death Claim Intimation Form","purpose":"claim","insurer":{"slug":"bandhan-life-insurance","name":"Bandhan Life Insurance Limited"},"source_pdf":"https://www.bandhanlife.com/sites/default/files/asset/2026-04/Claimant_Statement%20-%20Affinity.pdf","sha256":"6b7274e96e858b929160e65dca8f69ccffeccf5ffacf61331a78f4ef3d74cf69","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for notifying a death claim under a group insurance policy and is filled by the beneficiary or claimant.","notes":["Form to be filled by the beneficiary in BLOCK LETTERS.","Policy benefit payable only if policy is in force on date of event and all conditions are met.","Submission of this form does not mean claim acceptance.","Bandhan Life may call for additional documents as needed.","Regulatory guidelines require payouts to be credited directly to bank accounts.","Witness declaration must be signed by an official of MPH or a person of local standing / Special Executive Magistrate / Notary / Lawyer / Class 1 Gazetted Officer."],"title":"Affinity-Group Death Claim Intimation Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Group Policyholder's Details","fields":[{"help":"","type":"text","label":"Name of Master Policy Holder","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Master Policy No","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant/beneficiary"},{"title":"Information of the Member Insured - Details of Deceased Life Assured","fields":[{"help":"","type":"text","label":"Name","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":"Last Occupation","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Employer's Name","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant/beneficiary"},{"title":"Details of Claim","fields":[{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Death","options":[],"required":null,"pdf_field":""},{"help":"Select one","type":"choice","label":"Cause of Death","options":["Natural","Accident","Suicide"],"required":null,"pdf_field":""},{"help":"Select one","type":"choice","label":"Place of Death","options":["Hospital/Clinic","Residence","Office","Others"],"required":null,"pdf_field":""}],"filled_by":"claimant/beneficiary"},{"title":"Hospitalisation / Illness History in Last 5 Years","fields":[{"help":"If any","type":"text","label":"Nature of illness / ailment","options":[],"required":false,"pdf_field":""},{"help":"If any, format DD/MM/YYYY","type":"date","label":"Date of diagnosis","options":[],"required":false,"pdf_field":""},{"help":"If any, format DD/MM/YYYY","type":"date","label":"Date of admission","options":[],"required":false,"pdf_field":""},{"help":"If any, format DD/MM/YYYY","type":"date","label":"Date of discharge","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name & address of doctor last visited","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant/beneficiary"},{"title":"Beneficiary Information","fields":[{"help":"","type":"text","label":"Beneficiary Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Relation with the Deceased","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant/beneficiary"},{"title":"Bank Details","fields":[{"help":"","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"e.g. Savings, Current","type":"text","label":"Account Type","options":[],"required":null,"pdf_field":""},{"help":"Bank account number of beneficiary","type":"text","label":"Account No.","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"Phone number of beneficiary","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Email address of beneficiary","type":"email","label":"E-Mail ID","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant/beneficiary"},{"title":"Declaration & Authorization by Beneficiary","fields":[{"help":"Name of claimant/beneficiary signing","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Date of signing, format DD/MM/YYYY","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant/beneficiary"},{"title":"Vernacular Declaration (if applicable)","fields":[{"help":"Witness must sign if claimant signs in vernacular or thumb impression","type":"signature","label":"Signature of the Witness","options":[],"required":null,"pdf_field":""},{"help":"Address of witness","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of the Witness","options":[],"required":null,"pdf_field":""},{"help":"Phone number of witness","type":"phone","label":"Contact No. of the Witness","options":[],"required":null,"pdf_field":""}],"filled_by":"witness"}],"deadlines":[],"applies_to":"death claims under group policies","attachments":["Copy of death certificate issued by appropriate authority (e.g: Municipal Corporation)","KYC documents of claimant (PAN or Form No. 60 and one of Aadhaar Card, Passport (unexpired), Driving License (unexpired), Voter's Identity Card, Job card issued by NREGA duly signed by an officer of the State Government)","One recent photograph of the claimant","Copy of self-attested cancelled cheque/bank passbook of the beneficiary","Copy of certificate of insurance","For Death due to accident/suicide: Copy of First Information Report (FIR), Inquest Report / Panchnama, Copy of Post-Mortem Report","For Death due to accident/suicide: Copy of cause of death certificate issued by treating doctor, Medical records (admission notes, discharge/death summary, test reports etc.)"],"declarations":["The claimant declares that the statements made are true and that submission of the 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 shall discharge Bandhan Life Insurance Ltd.'s liability."],"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/50-affinity-group-death-claim-intimation-form"}