{"id":59,"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_Marathi.pdf","sha256":"0dea13e529b9e1c80d530b888df5496527cf5d3e27e0019c5e48890ca0ae7c00","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 form must be filled by the person legally entitled to the policy money.","Please submit all investigation reports along with the discharge summary and surgeon's report.","The form must be witnessed by one of the specified authorized persons such as Block Development Officer, Bank Manager, Company Officer, Gazetted Officer, Head Master/Principal, Magistrate, or Notary Public.","For illiterate claimants, the vernacular declaration must be completed by a witness unconnected with the company whose identity can be easily established."],"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/ नाव","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address/ प󰊋ा","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation/ 󰈄यवसाय","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Office Address/ काया󰇟लयाचा प󰊋ा","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Residence Telephone No. (with STD code)/ 󰇎नवासाचा 󰊆र󰇸वनी 󰈚मांक (एसटीडी कोडसह)","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No./ मोबाईल 󰈚मांक","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 󰈗या 󰇏व󰇑श󰊦 गंभीर आजारासाठी दावा कर󰇴यात येत आहे, तो नमूद करा","options":[],"required":true,"pdf_field":""},{"help":"State reason for hospital admission","type":"text","label":"Immediate Cause of Admission into a hospital/Nature of complaint / 󰊁󰇧णालयात दाखल हो󰇴याचे ता󰇵काळ कारण / त󰈚ारीचे 󰈈व󰊂प","options":[],"required":true,"pdf_field":""},{"help":"Mention diagnosis or surgery details","type":"text","label":"Diagnosis arrived at/Surgery performed / केलेली 󰇎नदान 󰈯󰇎󰈚या / कर󰇴यात आलेली श󰈈󰈪󰇎󰈚या","options":[],"required":true,"pdf_field":""},{"help":"Date when diagnosis or surgery was done","type":"date","label":"Date of Diagnosis of illness/ Surgery / आजाराचे 󰇎नदान / श󰈈󰈪󰇎󰈚येची तारीख","options":[],"required":true,"pdf_field":""},{"help":"Provide hospital name and address","type":"text","label":"Name and Address of the Hospital(s) / 󰊁󰇧णालयाचे नाव व प󰊋ा","options":[],"required":true,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"Policy No / पॉ󰇒लसी 󰈚मांक","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age/ वय","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"In Years/ वषा󰇠म󰇸ये","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/ बँकेचे नाव","options":[],"required":true,"pdf_field":""},{"help":"Your bank account number","type":"text","label":"Bank Account No./ खाते 󰈚मांक","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Treatment and Medical Details","fields":[{"help":"Date when treatment started","type":"date","label":"Date of commencement of treatment/ उपचार सु󰊂 कर󰇴याची तारीख","options":[],"required":null,"pdf_field":""},{"help":"Describe the treatment given","type":"text","label":"Treatment given/ दे󰇴यात आलेले उपचार","options":[],"required":null,"pdf_field":""},{"help":"List investigations and tests done","type":"text","label":"Investigations done and tests conducted/ केले󰈂या तपास󰇴या व चाच󰇴या","options":[],"required":null,"pdf_field":""},{"help":"Provide contact 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/ आजारा󰇪या काळात स󰈂ला घेतले󰈂या डॉ󰇥टरांचे / वै󰊣क󰇛य के󰇝󰈬ांचे नाव, प󰊋ा आ󰇑ण 󰊆र󰇸वनी 󰈚मांक कृपया नमूद करा.","options":[],"required":null,"pdf_field":""},{"help":"List doctors' names, addresses and illnesses treated in last 3 years","type":"table","label":"Name & addresses of the Doctors who treated you during the last three years & the illnesses for which the treatment was availed./ मागील तीन वषा󰇠म󰇸ये आप󰈂यावर उपचार केले󰈂या डॉ󰇥टरांची नावे व प󰊋े आ󰇑ण संबं󰇐धत आजारांची मा󰇎हती, 󰈗यासाठी उपचार घे󰇴यात आले होते.","options":[],"required":null,"pdf_field":""},{"help":"Duration of the illness","type":"text","label":"Duration of Illness/ आजाराचा कालावधी","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?/ जीवन 󰇏वमाधारकाने आजाराची त󰈚ार 󰈯थम कधी केली 󰇎क󰇝वा 󰈘याचे ल󰊈णे कधी अनुभवले?","options":[],"required":null,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of the Doctor / डॉ󰇥टरचे नाव","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address / प󰊋ा","options":[],"required":null,"pdf_field":""},{"help":"Consultation period","type":"text","label":"Period of Consultation / स󰈂लामसलतीचा कालावधी","options":[],"required":null,"pdf_field":""},{"help":"Contact number with period","type":"phone","label":"Contact No. (From – To) / संपक󰇟 󰈚मांक (पासून – पय󰇠त)","options":[],"required":null,"pdf_field":""},{"help":"Name of disease or disorder","type":"text","label":"Disease/ Disorder / आजार / 󰇏वकार","options":[],"required":null,"pdf_field":""},{"help":"Hospital or doctor's name","type":"text","label":"Name of Hospital/Doctor / 󰊁󰇧णालय/डॉ󰇥टरचे नाव","options":[],"required":null,"pdf_field":""},{"help":"Hospital or doctor's address","type":"text","label":"Address / प󰊋ा","options":[],"required":null,"pdf_field":""},{"help":"Telephone number","type":"phone","label":"Tel. No. / 󰊆र󰇸वनी 󰈚मांक","options":[],"required":null,"pdf_field":""},{"help":"Registration or license number","type":"text","label":"Registration/ License No / नो󰇝दणी / परवाना 󰈚मांक","options":[],"required":null,"pdf_field":""},{"help":"Hospital admission date","type":"date","label":"Date of Admission / दाखल हो󰇴याची तारीख","options":[],"required":null,"pdf_field":""},{"help":"Date of surgery if performed","type":"date","label":"Date of Operation (if any)/ श󰈈󰈪󰇎󰈚येची तारीख (अस󰈂यास)","options":[],"required":null,"pdf_field":""},{"help":"Hospital discharge date","type":"date","label":"Date of Discharge/ 󰊁󰇧णालयातून 󰇎ड󰈈चाज󰇟ची तारीख","options":[],"required":null,"pdf_field":""},{"help":"Provide details of critical illness or Mediclaim coverage","type":"text","label":"Details of Critical Insurance coverage/Mediclaim coverage of the Life Assured/ जीवन 󰇏वमाधारका󰇪या गंभीर आजार 󰇏वमा कवच / मे󰇎ड󰇥लेम कवचाची मा󰇎हती","options":[],"required":null,"pdf_field":""},{"help":"Policy number for coverage","type":"text","label":"Policy No / पॉ󰇒लसी 󰈚मांक","options":[],"required":null,"pdf_field":""},{"help":"Name of insurer","type":"text","label":"Insurer/ 󰇏वमाकता󰇟","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)/ 󰇏वमा कवचाचा 󰈯कार (उदा. मे󰇎ड󰇥लेम 󰇎क󰇝वा गंभीर आजार 󰇏वमा)","options":[],"required":null,"pdf_field":""},{"help":"Effective date of coverage","type":"date","label":"Effective Date/ अमलात ये󰇴याची तारीख","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Claimant / दावा करणा󰈀याचे 󰈈वा󰊈री","options":[],"required":true,"pdf_field":""},{"help":"Claimant's address","type":"text","label":"Address of the Claimant / दावा करणा󰈀याचा प󰊋ा","options":[],"required":null,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness / सा󰊈ीदाराची 󰈈वा󰊈री","options":[],"required":true,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of witness / सा󰊈ीदाराचे नाव","options":[],"required":true,"pdf_field":""},{"help":"Witness address","type":"text","label":"Address of witness/ सा󰊈ीदाराचा प󰊋ा","options":[],"required":true,"pdf_field":""},{"help":"Witness contact number","type":"phone","label":"Contact no. of witness/ सा󰊈ीदाराचा संपक󰇟 󰈚मांक","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vernacular Declaration (for illiterate claimant)","fields":[{"help":"Name of witness explaining the form","type":"text","label":"Name of the Witness/ सा󰊈ीदाराचे नाव","options":[],"required":true,"pdf_field":""},{"help":"Address of witness","type":"text","label":"Address of the Witness/ सा󰊈ीदाराचा प󰊋ा","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of the Witness / सा󰊈ीदाराची 󰈈वा󰊈री","options":[],"required":true,"pdf_field":""},{"help":"Witness contact number","type":"phone","label":"Contact No. of the Witness/ सा󰊈ीदाराचा संपक󰇟 󰈚मांक","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 accurate.","Submission of this form does not constitute admission of insurance coverage or waiver of rights by the company.","The claimant authorizes any doctor, hospital, insurance company, 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."],"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/59-application-for-critical-illness-claim"}