{"id":58,"title":"APPLICATION FOR CRITICAL ILLNESS CLAIM / गंभीर बीमारी दावे के लिए आवेदन","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_Hindi.pdf","sha256":"c271676780d8b0db61d122b8f39be9d1a28eed5b27d221e6284131c6b8e9c4c6","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' sections are mandatory.","The claimant must be the holder of the bank account provided.","The form must be witnessed by one of the authorized persons listed (e.g. Block Development Officer, Bank Manager with rubber stamp, Company officer not below Manager, Gazetted Officer, Head Master/Principal of Govt. School, Magistrate, Notary Public).","Use clear and unambiguous answers.","Submit original investigation reports and discharge summary along with this form."],"title":"APPLICATION FOR CRITICAL ILLNESS CLAIM / गंभीर बीमारी दावे के लिए आवेदन","submit":{"to":"Bandhan Life Insurance Ltd","how":"","address":"Registered office - A - 201, 2nd Floor, Leela Business Park, Andheri-Kurla Road, Andheri (E), Mumbai - 400059"},"purpose":"claim","sections":[{"title":"Information about the Life Assured / बीमित व्यक्ति की जानकारी","fields":[{"help":"","type":"text","label":"Name/ नाम","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address/ पता","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation/ व्यवसाय","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Office Address/ कार्यालय पता","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Residence Telephone No. (with STD code)/ निवास टेलीफोन नंबर (एसटीडी कोड सहित)","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No./ मोबाइल नंबर","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/ कृपया उस विशेष गंभीर बीमारी का उल्लेख करें जिसके लिए दावा किया जा रहा है।","options":[],"required":true,"pdf_field":""},{"help":"Describe reason for hospital admission","type":"text","label":"Immediate Cause of Admission into a hospital/Nature of complaint / अस्पताल में भर्ती होने का तत्काल कारण/शिकायत का प्रकार","options":[],"required":true,"pdf_field":""},{"help":"Mention diagnosis or surgery details","type":"text","label":"Diagnosis arrived at/Surgery performed / निदान किया/सर्जरी की गई","options":[],"required":true,"pdf_field":""},{"help":"Date format as DD/MM/YYYY","type":"date","label":"Date of Diagnosis of illness/ Surgery / बीमारी के निदान/सर्जरी की तिथि","options":[],"required":true,"pdf_field":""},{"help":"Provide full hospital name and address","type":"text","label":"Name and Address of the Hospital(s) / अस्पताल(ओं) का नाम और पता","options":[],"required":true,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"Policy No / पॉलिसी नंबर","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age/ आयु","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details / बैंक खाता विवरण","fields":[{"help":"Name of the bank where account is held","type":"text","label":"Bank Name/ बैंक का नाम","options":[],"required":true,"pdf_field":""},{"help":"Account number of the claimant","type":"text","label":"Bank Account No./ बैंक खाता नंबर","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Information about the Critical Illness and Treatment","fields":[{"help":"Date format as DD/MM/YYYY","type":"date","label":"Date of commencement of treatment/ उपचार शुरू होने की तारीख","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment provided","type":"text","label":"Treatment given/ दिया गया उपचार","options":[],"required":null,"pdf_field":""},{"help":"List investigations and tests done","type":"text","label":"Investigations done and tests conducted/ किए गए परीक्षण और जांच","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/ कृपया बीमारी के दौरान परामर्श लेने वाले डॉक्टर/चिकित्सा केंद्रों का नाम, पता और टेलीफोन नंबर बताएं","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./ पिछले तीन वर्षों के दौरान जिन डॉक्टरों ने आपका इलाज किया उनके नाम और पते तथा जिन बीमारियों के लिए उपचार लिया गया, उनका विवरण।","options":[],"required":null,"pdf_field":""},{"help":"Specify duration of illness","type":"text","label":"Duration of Illness/ बीमारी की अवधि","options":[],"required":null,"pdf_field":""},{"help":"Date format as DD/MM/YYYY","type":"date","label":"When did the Life Assured first complain of the illness or experience symptoms of the same?/ बीमित व्यक्ति ने पहली बार इस बीमारी की शिकायत कब की या इसके लक्षण कब अनुभव किए?","options":[],"required":null,"pdf_field":""},{"help":"Name of treating doctor","type":"text","label":"Name of the Doctor / डॉक्टर का नाम","options":[],"required":null,"pdf_field":""},{"help":"Address of doctor or hospital","type":"text","label":"Address / पता","options":[],"required":null,"pdf_field":""},{"help":"Specify consultation period","type":"text","label":"Period of Consultation / परामर्श की अवधि","options":[],"required":null,"pdf_field":""},{"help":"Contact numbers during consultation period","type":"text","label":"Contact No. (From – To) / संपर्क नंबर (से – तक)","options":[],"required":null,"pdf_field":""},{"help":"Name of disease or disorder treated","type":"text","label":"Disease/ Disorder / रोग/ विकार","options":[],"required":null,"pdf_field":""},{"help":"Name of hospital or doctor","type":"text","label":"Name of Hospital/Doctor / अस्पताल/डॉक्टर का नाम","options":[],"required":null,"pdf_field":""},{"help":"Address of hospital or doctor","type":"text","label":"Address / पता","options":[],"required":null,"pdf_field":""},{"help":"Telephone number","type":"phone","label":"Tel. No. / टेलीफोन नंबर","options":[],"required":null,"pdf_field":""},{"help":"Registration or license number of doctor/hospital","type":"text","label":"Registration/ License No / पंजीकरण/ लाइसेंस नंबर","options":[],"required":null,"pdf_field":""},{"help":"Date format as DD/MM/YYYY","type":"date","label":"Date of Admission / भर्ती होने की तिथि","options":[],"required":null,"pdf_field":""},{"help":"Date format as DD/MM/YYYY","type":"date","label":"Date of Operation (if any)/ ऑपरेशन की तिथि (यदि कोई हो)","options":[],"required":false,"pdf_field":""},{"help":"Date format as DD/MM/YYYY","type":"date","label":"Date of Discharge/ छुट्टी की तिथि","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/ बीमित व्यक्ति की गंभीर बीमा कवरेज/मेड़िकल कवरेज का विवरण","options":[],"required":null,"pdf_field":""},{"help":"Policy number of other coverage if any","type":"text","label":"Policy No / पॉलिसी नंबर","options":[],"required":false,"pdf_field":""},{"help":"Name of insurer for other coverage","type":"text","label":"Insurer/ बीमाकर्ता","options":[],"required":false,"pdf_field":""},{"help":"Select type of coverage","type":"choice","label":"Nature of coverage (i.e. Mediclaim or CI)/ कवरेज का प्रकार (जैसे मेड़िकल या क्रिटिकल इलनेस)","options":["Mediclaim","Critical Illness"],"required":false,"pdf_field":""},{"help":"Effective date of coverage","type":"date","label":"Effective Date/ प्रभावी तिथि","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration & Authorization / घोषणा और प्राधिकरण","fields":[{"help":"Place and date of signing","type":"text","label":"Signed at/ पर हस्ताक्षर किए गए (Place) on this/ इस पर (स्थान) Day of/ के दिन Month/ महीना Year/ वर्ष","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Claimant / दावेदार के हस्ताक्षर","options":[],"required":true,"pdf_field":""},{"help":"Claimant's address","type":"text","label":"Address of the Claimant / दावेदार का पता","options":[],"required":true,"pdf_field":""},{"help":"Witness must sign here","type":"signature","label":"Signature of Witness / गवाह के हस्ताक्षर","options":[],"required":true,"pdf_field":""},{"help":"Name of the witness","type":"text","label":"Name of witness / गवाह का नाम","options":[],"required":true,"pdf_field":""},{"help":"Address of the witness","type":"text","label":"Address of witness/ गवाह का पता","options":[],"required":true,"pdf_field":""},{"help":"Phone number of witness","type":"phone","label":"Contact no. of witness/ गवाह का संपर्क नंबर","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vernacular Declaration / स्थानीय भाषा में घोषणा","fields":[{"help":"Name of witness certifying explanation","type":"text","label":"Name of the Witness/ गवाह का नाम","options":[],"required":true,"pdf_field":""},{"help":"Address of witness","type":"text","label":"Address of the Witness/ गवाह का पता","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of the Witness / गवाह के हस्ताक्षर","options":[],"required":true,"pdf_field":""},{"help":"Phone number of witness","type":"phone","label":"Contact No. of the Witness/ गवाह का संपर्क नंबर","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 that submitting this form does not mean the company admits insurance was in force or waives any rights.","The claimant authorizes any doctor, hospital, insurance support organization, government agency, employer, or other entity to provide Bandhan Life Insurance Ltd with any information related to the insured's health, treatment, employment, finances, including sensitive information such as mental illness, drug/alcohol use, HIV/AIDS, or sexually transmitted diseases.","A photocopy of this authorization is as valid as the original.","For illiterate claimants, a witness certifies that the form contents were explained in a language understood by the claimant and that the claimant has affixed their thumb impression in the witness's presence."],"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/58-application-for-critical-illness-claim"}