{"id":57,"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_Bengali.pdf","sha256":"bbd964d5176007b351af7806dd49e0d8933f87366b96537099d6b5c5d873ca56","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 must be the holder of the bank account provided.","The form must be witnessed by one of the specified categories of persons.","For illiterate claimants, the vernacular declaration must be completed by a witness who explains the form and authenticates the thumb impression.","Submit original investigation reports and discharge summary along with this form."],"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/ নাম","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address/ ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation/ েপশা","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Office Address/ অিফেসর ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Residence Telephone No. (with STD code)/ বািড়র েটিলেফান নȼর (এস˘িড েকাডসহ)","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No./ েমাবাইল নȼর","options":[],"required":true,"pdf_field":""},{"help":"Specify the critical illness","type":"text","label":"Please state the specific critical illness for which the claim is being made/ দয়া কের েয িনিদঁɢ Ơরুতর েরােগর জনঁ দািব করা হেƺ, তা উেɕখ করুন।","options":[],"required":true,"pdf_field":""},{"help":"State reason for hospital admission","type":"text","label":"Immediate Cause of Admission into a hospital/Nature of complaint /  হাসপাতােল ভিতঁর তাˁƘিণক কারণ / অিভেযােগর Ȣকৃিত","options":[],"required":true,"pdf_field":""},{"help":"Mention diagnosis or surgery details","type":"text","label":"Diagnosis arrived at/Surgery performed / েরাগ িনণ˿য় / সȸȕ হওয়া অেɳাপচার","options":[],"required":true,"pdf_field":""},{"help":"Date when diagnosis or surgery was done","type":"date","label":"Date of Diagnosis of illness/ Surgery / েরাগ িনণ˿েয়র / অেɳাপচােরর তািরখ","options":[],"required":true,"pdf_field":""},{"help":"Provide hospital name and address","type":"text","label":"Name and Address of the Hospital(s) / হাসপাতাল(Ơিল)-র নাম ও ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"Policy No / পিলিস নȼর","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age/ বয়স","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"In Years/ বছের","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details","fields":[{"help":"Bank where claimant holds account","type":"text","label":"Bank Name/ বঁাংেকর নাম","options":[],"required":true,"pdf_field":""},{"help":"Claimant's bank account number","type":"text","label":"Bank Account No./ অঁাকাউȄ নȼর","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Information about the Critical Illness and Treatment","fields":[{"help":"Date when treatment started","type":"date","label":"Date of commencement of treatment/  িচিকৎসা ɖরুর তািরখ","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment provided","type":"text","label":"Treatment given/ Ȣদান করা িচিকৎসা","options":[],"required":null,"pdf_field":""},{"help":"List investigations and tests done","type":"text","label":"Investigations done and tests conducted/ করা তদȉ ও পরীƘা-িনরীƘা","options":[],"required":null,"pdf_field":""},{"help":"Provide details of doctors or medical centers consulted","type":"text","label":"Please state the Name, address and Telephone numbers of the Doctor(s)/ Medical Centers consulted during the illness/অনুƩহ কের েরাগ চলাকালীন পরামশ˿ েনওয়া িচিকৎসক(েদর) / িচিকৎসা েকȐƠেলার নাম, ˙কানা ও েটিলেফান নȼর উেɕখ করুন।","options":[],"required":null,"pdf_field":""},{"help":"List doctors and illnesses treated in 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./গত িতন বছের আপনােক িচিকৎসা Ȣদানকারী িচিকৎসকেদর নাম ও ˙কানা এবং েযসব েরােগর জনঁ িচিকৎসা েনওয়া হেয়েছ, েসƠেলার িববরণ িদন।","options":[],"required":null,"pdf_field":""},{"help":"Duration of the illness","type":"text","label":"Duration of Illness/ েরােগর সময়কাল","options":[],"required":null,"pdf_field":""},{"help":"Date when symptoms first appeared","type":"date","label":"When did the Life Assured first complain of the illness or experience symptoms of the same?/ বীমাকৃত বঁিƐ Ȣথম কেব এই েরােগর অিভেযাগ কেরন বা এর উপসগ˿ অনুভব কেরন?","options":[],"required":null,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of the Doctor / িচিকৎসেকর নাম","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address / ˙কানা","options":[],"required":null,"pdf_field":""},{"help":"Consultation period","type":"text","label":"Period of Consultation / পরামেশ˿র সময়কাল","options":[],"required":null,"pdf_field":""},{"help":"Contact number during consultation period","type":"phone","label":"Contact No. (From – To) / েযাগােযাগ নȼর (হেত – পয˿ȉ)","options":[],"required":null,"pdf_field":""},{"help":"Name of disease or disorder","type":"text","label":"Disease/ Disorder / েরাগ / বঁািধ","options":[],"required":null,"pdf_field":""},{"help":"Hospital or doctor name","type":"text","label":"Name of Hospital/Doctor / হাসপাতাল/িচিকৎসেকর নাম","options":[],"required":null,"pdf_field":""},{"help":"Hospital or doctor address","type":"text","label":"Address / ˙কানা","options":[],"required":null,"pdf_field":""},{"help":"Telephone number","type":"phone","label":"Tel. No. / েটিলেফান নȼর","options":[],"required":null,"pdf_field":""},{"help":"Registration or license number","type":"text","label":"Registration/ License No / িনবȒন / লাইেসș নȼর","options":[],"required":null,"pdf_field":""},{"help":"Hospital admission date","type":"date","label":"Date of Admission / ভিতঁর তািরখ","options":[],"required":null,"pdf_field":""},{"help":"Date of surgery if performed","type":"date","label":"Date of Operation (if any)/ অেɳাপচােরর তািরখ (যিদ হেয় থােক)","options":[],"required":null,"pdf_field":""},{"help":"Hospital discharge date","type":"date","label":"Date of Discharge/ ছাড়পেǮর তািরখ","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any critical illness or mediclaim coverage","type":"text","label":"Details of Critical Insurance coverage/Mediclaim coverage of the Life Assured/ বীমাকৃত বঁিƐর Ơরুতর েরাগ িবমা/েমিডেƖম কভােরজ সȸিকঁত িববরণ","options":[],"required":null,"pdf_field":""},{"help":"Policy number for other coverage","type":"text","label":"Policy No / পিলিস নȼর","options":[],"required":null,"pdf_field":""},{"help":"Name of insurer for other coverage","type":"text","label":"Insurer/ বীমাকারী","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration & Authorization","fields":[{"help":"Specify type of coverage","type":"text","label":"Nature of coverage (i.e. Mediclaim or CI)/ িবমা কভােরেজর ধরণ (েযমন: েমিডেƖম বা িসআই)","options":[],"required":true,"pdf_field":""},{"help":"Date coverage became effective","type":"date","label":"Effective Date/ কায˿কর হওয়ার তািরখ","options":[],"required":true,"pdf_field":""},{"help":"Claimant's signature","type":"signature","label":"Signature of the Claimant / দািবদােরর ɻাƘর","options":[],"required":true,"pdf_field":""},{"help":"Claimant's address","type":"text","label":"Address of the Claimant / দািবদােরর ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Place and date of signing","type":"text","label":"Signed at/ ɻাƘিরত ɵান (Place) on this/ (ɵান) এই তািরেখ","options":[],"required":true,"pdf_field":""},{"help":"Day of signing","type":"number","label":"Day of/ িদেনর","options":[],"required":true,"pdf_field":""},{"help":"Month of signing","type":"text","label":"Month/ মাস","options":[],"required":true,"pdf_field":""},{"help":"Year of signing","type":"number","label":"Year/ বছর","options":[],"required":true,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Signature of Witness / সাƘীর ɻাƘর","options":[],"required":true,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of witness / সাƘীর নাম","options":[],"required":true,"pdf_field":""},{"help":"Address of witness","type":"text","label":"Address of witness/ সাƘীর ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Contact number of witness","type":"phone","label":"Contact no. of witness/ সাƘীর েযাগােযাগ নȼর","options":[],"required":true,"pdf_field":""},{"help":"Select the category of the witness","type":"choice","label":"The form must be witnessed by any one of the following / ফম˾˗ িনȶিলিখত েয েকােনা একজন সাƗীর Ǿারা সাƗঁȡাț হেত হেব:","options":["Block Development Officer / Ȳক উȕয়ন আিধকািরক","A Bank Manager of a Nationalized Bank with Rubber Stamp / রাবার ɯঁাȸসহ এক˘ জাতীয়কৃত বঁাংেকর মঁােনজার","An Officer of the Company not below the rank of Manager / েকাȸািনর মঁােনজার পদময˿াদার িনেচ নয় এমন েকােনা অিফসার","A Gazetted Officer / একজন েগেজেটড অিফসার","Head Master / Principal of a Govt. School / সরকাির িবদঁালেয়র Ȣধান িশƘক / িȢিșপাল","A Magistrate / একজন মঁািজেɰট","Notary Public / েনাটাির পাবিলক"],"required":true,"pdf_field":""}],"filled_by":"claimant and witness"},{"title":"Vernacular Declaration","fields":[{"help":"Name of witness who explained the form","type":"text","label":"Name of the Witness/ সাƘীর নাম","options":[],"required":true,"pdf_field":""},{"help":"Address of witness","type":"text","label":"Address of the Witness/ সাƘীর ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Signature of the Witness / সাƘীর ɻাƘর","options":[],"required":true,"pdf_field":""},{"help":"Contact number of witness","type":"phone","label":"Contact No. of the Witness/ সাƘীর েযাগােযাগ নȼর","options":[],"required":true,"pdf_field":""}],"filled_by":"witness for illiterate claimant"}],"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 clear.","Submitting this form does not mean the company admits insurance was in force or waives any rights.","The claimant authorizes any doctor, hospital, or related entity to provide information about the insured's health and treatment, including sensitive information.","A photocopy of this authorization is as valid as the original."],"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/57-application-for-critical-illness-claim"}