{"id":60,"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_Oriya.pdf","sha256":"6016a5fadb59c97ad738c3dcb96a865f46df51f756b32650160654cdb5649d76","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.","Use clear and unambiguous answers.","The vernacular declaration must be witnessed by an authorized person such as Block Development Officer, Bank Manager, Company Officer (Manager or above), Gazetted Officer, Head Master/Principal of Govt. School, Magistrate, Notary Public.","Submit original investigation reports and discharge summary with surgeon's report."],"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/ ନାମ","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address/ ଠିକଣା","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation/ େପଶା","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Office Address/ କାଯର୍ɨାଳୟ ଠିକଣା","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Residence Telephone No. (with STD code)/ ଘର େଫାନ ନǯର (ଏȚିଡି ସହିତ)","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No./ େମାବାଇଲ ନǯର","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/ ଦୟାକରି ଉେǺଖ କରǏୁ େଯ େକଉଁ ନିLJʌȈ ଗୁରୁତର େରାଗ ପାଇଁ ଦାବି କରାଯାଉଛି","options":[],"required":true,"pdf_field":""},{"help":"State reason for hospital admission","type":"text","label":"Immediate Cause of Admission into a hospital/Nature of complaint / ହȖିଟାଲ୍ କୁ ଭƹʌ େହବାର ȶଥମିକ କାରଣ / ଅଭିେଯାଗର Șଭାବ","options":[],"required":true,"pdf_field":""},{"help":"Mention diagnosis or surgery details","type":"text","label":"Diagnosis arrived at/Surgery performed / େରାଗ ଚିȞଟ/ କାଯର୍ɨବାହି ସଂଚାଳିତ ସେଜର୍ରି","options":[],"required":true,"pdf_field":""},{"help":"Date when diagnosis or surgery was done","type":"date","label":"Date of Diagnosis of illness/ Surgery / ଚିȞଟ େହବାର ତାରିଖ / ସେଜର୍ରି ତାରିଖ","options":[],"required":true,"pdf_field":""},{"help":"Hospital where treatment was received","type":"text","label":"Name and Address of the Hospital(s) / ହȖିଟାଲ୍ (ମାେନ)ର ନାମ ଓ ଠିକଣା","options":[],"required":true,"pdf_field":""},{"help":"Policy number of the insured","type":"text","label":"Policy No / ପଲିସି ନǯର","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age/ ବୟସ","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/ ବɨାƝ ନାମ","options":[],"required":true,"pdf_field":""},{"help":"Account number of the claimant; claimant must be account holder","type":"text","label":"Bank Account No./ ଖାତା ନǯର","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Treatment and Medical History","fields":[{"help":"Date when treatment started","type":"date","label":"Date of commencement of treatment/ ଚିକିǂା ଆରǰ ତାରିଖ","options":[],"required":null,"pdf_field":""},{"help":"Details of treatment provided","type":"text","label":"Treatment given/ ଦିଆଯାଇଥିବା ଚିକିǂା","options":[],"required":null,"pdf_field":""},{"help":"List investigations and tests done","type":"text","label":"Investigations done and tests conducted/ କରାଯାଇଥିବା ତଦǏ ଓ ପରୀƒା","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/ ଦୟାକରି େରାଗ ସମୟେର ସǬକର୍ କରାଯାଇଥିବା ଡାƌରମାେନ/ ଚିକିǂା େକǕମାେନର ନାମ, ଠିକଣା ଓ େଫାନ୍ ନǯର ଉେǺଖ କରǏୁ","options":[],"required":null,"pdf_field":""},{"help":"List doctors, their 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./ ଗତ ତିନି ବଷର୍େର େଯଉଁ ଡାƌରମାେନ ଚିକିǂା କରିଥିେଲ ଓ େସହି ଚିକିǂା ପାଇଁ ଥିବା େରାଗର ବିବରଣୀ ସହିତ ତାƝ ନାମ ଓ ଠିକଣା ଦିଅǏୁ","options":[],"required":null,"pdf_field":""},{"help":"Duration of the illness","type":"text","label":"Duration of Illness/ େରାଗର ଅବଧି","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?/ ବୀମିତ ବɨƌି ȶଥେମ େକେବ ଏହି େରାଗ ନିମିେƹ ଅଭିେଯାଗ କେଲ ବା ଲƒଣ ଅନୁଭବ କେଲ?","options":[],"required":null,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of the Doctor / ଡାƌରƝର ନାମ","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address / ଠିକଣା","options":[],"required":null,"pdf_field":""},{"help":"Consultation period (from-to dates)","type":"text","label":"Period of Consultation / ପରାମଶର୍ ଅବଧି","options":[],"required":null,"pdf_field":""},{"help":"Contact number during consultation period","type":"phone","label":"Contact No. (From – To) / େଯାଗାେଯାଗ ନǯର (େଯଉଁ ତାରିଖରୁ – େକଉଁ ତାରିଖ ପଯର୍ɨǏ)","options":[],"required":null,"pdf_field":""},{"help":"Name of disease or disorder","type":"text","label":"Disease/ Disorder / େରାଗ / ବିକୃତି","options":[],"required":null,"pdf_field":""},{"help":"Hospital or doctor name","type":"text","label":"Name of Hospital/Doctor / ହȖିଟାଲ୍/ଡାƌରƝର ନାମ","options":[],"required":null,"pdf_field":""},{"help":"Hospital or doctor address","type":"text","label":"Address / ଠିକଣା","options":[],"required":null,"pdf_field":""},{"help":"Telephone number","type":"phone","label":"Tel. No. / େଫାନ୍ ନǯର","options":[],"required":null,"pdf_field":""},{"help":"Registration or license number of hospital/doctor","type":"text","label":"Registration/ License No / ନିବǗନ / ଲାଇେସǓ ନǯର","options":[],"required":null,"pdf_field":""},{"help":"Hospital admission date","type":"date","label":"Date of Admission / ଭତʌ େହବାର ତାରିଖ","options":[],"required":null,"pdf_field":""},{"help":"Date of surgery if performed","type":"date","label":"Date of Operation (if any)/ ଯଦି ଥାଏ େତେବ ସେଜର୍ରି ତାରିଖ","options":[],"required":false,"pdf_field":""},{"help":"Hospital discharge date","type":"date","label":"Date of Discharge/ ଡିସɋାଜର୍ ତାରିଖ","options":[],"required":null,"pdf_field":""},{"help":"Details of insurance or mediclaim coverage","type":"text","label":"Details of Critical Insurance coverage/Mediclaim coverage of the Life Assured/ ବୀମିତ ବɨƌିƝର ଗୁରୁତର ବୀମା କଭେରଜ୍ / େମଡିେକɠମ୍ କଭେରଜ୍ ବିଷୟେର ବିବରଣୀ","options":[],"required":null,"pdf_field":""},{"help":"Policy number for coverage","type":"text","label":"Policy No / ପଲିସି ସଂଖɨା","options":[],"required":null,"pdf_field":""},{"help":"Name of insurer","type":"text","label":"Insurer/ ବୀମା କǬାନୀ","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration & Authorization","fields":[{"help":"Place and date of signing","type":"text","label":"Signed at/ ସାଇନ୍ କରାଯାଇଛି (Place) on this/ (Ȕାନ) ଏଥିେର Day of/ ଦିନ Month/ ମାସ Year/ ବଷର୍","options":[],"required":true,"pdf_field":""},{"help":"Claimant's signature","type":"signature","label":"Signature of the Claimant / ଦାବିକାରୀƝର ଦȒଖତ","options":[],"required":true,"pdf_field":""},{"help":"Claimant's address","type":"text","label":"Address of the Claimant / ଦାବିକାରୀƝର ଠିକଣା","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness / ସାƒୀƝ ଦȒଖତ","options":[],"required":true,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of witness / ସାƒୀƝ ନାମ","options":[],"required":true,"pdf_field":""},{"help":"Witness address","type":"text","label":"Address of witness/ ସାƒୀƝ ଠିକଣା","options":[],"required":true,"pdf_field":""},{"help":"Witness contact number","type":"phone","label":"Contact no. of witness/ ସାƒୀƝ େଫାନ୍","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vernacular Declaration (for illiterate claimant)","fields":[{"help":"Name of the person explaining the form","type":"text","label":"Name of the Witness/ ସାƒୀƝ ନାମ","options":[],"required":true,"pdf_field":""},{"help":"Address of the witness","type":"text","label":"Address of the Witness/ ସାƒୀƝ ଠିକଣା","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of the Witness / ସାƒୀƝ ଦȒଖତ","options":[],"required":true,"pdf_field":""},{"help":"Witness contact number","type":"phone","label":"Contact No. of the Witness/ ସାƒୀƝ େଫାନ୍","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 authorizes Bandhan Life Insurance Ltd to obtain any medical, employment, financial or insurance information related to the claim.","A photocopy of the authorization is as valid as the original.","The claimant consents to disclosure of health information including mental illness, drug/alcohol use, HIV/AIDS and sexually transmitted diseases.","In case of illiterate claimant, the form must be explained in a language understood by the claimant and witnessed by an authorized person."],"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/60-application-for-critical-illness-claim"}