{"id":56,"title":"APPLICATION FOR CRITICAL ILLNESS 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/Claim%20Form-%20Critical%20Illness_Kannada.pdf","sha256":"95b635cff195e20ae2fb18db5d2d518ca71145d2a2e1abd1a513f476402a29a6","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for making a critical illness insurance claim and is to be filled by the person legally entitled to the policy money (claimant).","notes":["All fields under 'Information about the Life Assured' and 'Bank Account Details' are mandatory.","The claimant should be the holder of the bank account provided.","Please submit original investigation reports and discharge summary along with this form.","The vernacular declaration must be witnessed by an authorized person such as a Block Development Officer, Bank Manager, Company Officer, Gazetted Officer, Head Master/Principal, Magistrate, Notary Public."],"title":"APPLICATION FOR CRITICAL ILLNESS CLAIM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Information about the Life Assured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Office Address","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Residence Telephone No. (with STD code)","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.","options":[],"required":true,"pdf_field":""},{"help":"Specify the illness","type":"text","label":"Please state the specific critical illness for which the claim is being made","options":[],"required":true,"pdf_field":""},{"help":"Describe the cause or complaint","type":"text","label":"Immediate Cause of Admission into a hospital/Nature of complaint","options":[],"required":true,"pdf_field":""},{"help":"Provide diagnosis or surgery details","type":"text","label":"Diagnosis arrived at/Surgery performed","options":[],"required":true,"pdf_field":""},{"help":"Date format as per local standard","type":"date","label":"Date of Diagnosis of illness/ Surgery","options":[],"required":true,"pdf_field":""},{"help":"Provide full hospital details","type":"text","label":"Name and Address of the Hospital(s)","options":[],"required":true,"pdf_field":""},{"help":"Your policy number","type":"text","label":"Policy No","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details","fields":[{"help":"Name of the bank where account is held","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Account number must be held by claimant","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Treatment and Medical Details","fields":[{"help":"","type":"date","label":"Date of commencement of treatment","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment provided","type":"text","label":"Treatment given","options":[],"required":null,"pdf_field":""},{"help":"List investigations and tests","type":"text","label":"Investigations done and tests conducted","options":[],"required":null,"pdf_field":""},{"help":"Provide full contact details","type":"text","label":"Please state the Name, address and Telephone numbers of the Doctor(s)/ Medical Centers consulted during the illness","options":[],"required":null,"pdf_field":""},{"help":"Provide details for last 3 years","type":"text","label":"Name & addresses of the Doctors who treated you during the last three years & the illnesses for which the treatment was availed","options":[],"required":null,"pdf_field":""},{"help":"Specify duration","type":"text","label":"Duration of Illness","options":[],"required":null,"pdf_field":""},{"help":"Date of first symptoms or complaint","type":"date","label":"When did the Life Assured first complain of the illness or experience symptoms of the same?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Doctor","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"From - To dates","type":"text","label":"Period of Consultation","options":[],"required":null,"pdf_field":""},{"help":"Contact number during consultation period","type":"phone","label":"Contact No. (From – To)","options":[],"required":null,"pdf_field":""},{"help":"Name of disease or disorder","type":"text","label":"Disease/ Disorder","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Hospital/Doctor","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Tel. No.","options":[],"required":null,"pdf_field":""},{"help":"Doctor or hospital registration/license number","type":"text","label":"Registration/ License No","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"If surgery was performed","type":"date","label":"Date of Operation (if any)","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other insurance coverage","type":"text","label":"Details of Critical Insurance coverage/Mediclaim coverage of the Life Assured","options":[],"required":null,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No","options":[],"required":null,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Insurer","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration & Authorization","fields":[{"help":"","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Witness","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of witness","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address of witness","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact no. of witness","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vernacular Declaration","fields":[{"help":"Witness who explained the form to illiterate claimant","type":"text","label":"Name of the Witness","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address of the Witness","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Witness","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact No. of the Witness","options":[],"required":true,"pdf_field":""}],"filled_by":"witness"}],"deadlines":[],"applies_to":"Critical Illness claims under Bandhan Life Insurance policies","attachments":["All investigation reports (e.g. Blood reports, ECG, Angiography, Histopathology etc.)","Discharge summary from Hospital","Report of operating surgeon","Any other related report(s)"],"declarations":["The claimant declares that all answers and statements are true and agrees that submission of this form does not admit insurance coverage or waive rights.","The claimant authorizes any doctor, hospital, medical professional, insurance company, employer, or other entity to provide information related to the insured's health, treatment, and finances to Bandhan Life Insurance Ltd.","A photocopy of this authorization is as valid as the original.","In case of illiterate claimant, the form must be explained by a witness who certifies the claimant's understanding and thumb impression."],"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/56-application-for-critical-illness-claim"}