{"id":64,"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_Telugu.pdf","sha256":"0d1941bb07b9b2d5939588be195b894f246c93c5e153ca981bf46d9bf8cc70b8","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.","Please submit original investigation reports and discharge summary along with this form.","In case of illiterate claimant, the form must be witnessed by a person of standing unconnected with the company whose identity can be easily established.","The form must be witnessed by one of the following: Block Development Officer, Bank Manager of a Nationalized Bank with Rubber Stamp, Officer of the Company not below the rank of Manager, Gazetted Officer, Head Master/Principal of a Govt. School, 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/ పేరు","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address/ చిరునామాt","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation/ వృతిƕ","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Office Address/ కారాƟలయ చిరునామా","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Residence Telephone No. (with STD code)/ ఇంటి ఫోన నంబర – (STD కోడ తో)","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No./ మొబైల నంబర","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/ దయచేసి కెƢ యిమ చేయబడిన నిరిƗ షƐ పా","options":[],"required":true,"pdf_field":""},{"help":"Reason for hospital admission","type":"text","label":"Immediate Cause of Admission into a hospital/Nature of complaint / హాసిƚటల లో చేరిƚంచిన తక̀ణ కారణం / ఫిరాƟదు సƤభావం","options":[],"required":true,"pdf_field":""},{"help":"Diagnosis or surgery details","type":"text","label":"Diagnosis arrived at/Surgery performed / నిరƔ యించిన వాƟధి / నిరƤహించిన శసƪ చికితƧ","options":[],"required":true,"pdf_field":""},{"help":"Date when diagnosis or surgery was done","type":"date","label":"Date of Diagnosis of illness/ Surgery / వాƟధి / శసƪ చికితƧ నిరాƘ రణ తేదీ","options":[],"required":true,"pdf_field":""},{"help":"Hospital name and address","type":"text","label":"Name and Address of the Hospital(s) / హాసిƚటల(లు) పేరు మరియు చిరునామా","options":[],"required":true,"pdf_field":""},{"help":"Your insurance policy number","type":"text","label":"Policy No / పాలసీ సంఖƟ","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age/ వయసుƧ","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details","fields":[{"help":"Name of the bank where claimant holds account","type":"text","label":"Bank Name/ బాƟంక పేరు","options":[],"required":true,"pdf_field":""},{"help":"Bank account number of the claimant","type":"text","label":"Bank Account No./ ఖాతా సంఖƟ","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Medical Treatment Details","fields":[{"help":"Date when treatment started","type":"date","label":"Date of commencement of treatment/ చికితƧ పా రంభ తేది","options":[],"required":null,"pdf_field":""},{"help":"Details of treatment provided","type":"text","label":"Treatment given/ ఇచిƊన చికితƧ","options":[],"required":null,"pdf_field":""},{"help":"List of investigations and tests done","type":"text","label":"Investigations done and tests conducted/ నిరƤహించిన పరీక̀లు మరియు పరిశోధనలు","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/ వాƟధి సమయంలో సంపƠ దించిన డాకƐ రుƢ / వైదƟ కేందా ల పేరు, చిరునామా మరియు ఫోన నంబరుƢ ఇవƤండి","options":[],"required":null,"pdf_field":""},{"help":"List doctors and treatments 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./ గత మూడు సంవత్సరాలలో మీకు చికిత్స చేసిన డాక్టర్ల పేర్లు మరియు చిరునామాలు మరియు వారు చేసిన చికిత్సలు.","options":[],"required":null,"pdf_field":""},{"help":"Duration of the illness","type":"text","label":"Duration of Illness/ వాƟధి వƟవధి","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?/ బీమా పొందిన వƟకిƕ తొలిసారిగా వాƟధి గురించి ఎపుƚడు ఫిరాƟదు చేశాడు లేదా లక̀ణాలు అనుభవించాడు?","options":[],"required":null,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of the Doctor / వైదుƟని పేరు","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address / చిరునామా","options":[],"required":null,"pdf_field":""},{"help":"Consultation period","type":"text","label":"Period of Consultation / సంపƠ దించిన వƟవధి","options":[],"required":null,"pdf_field":""},{"help":"Contact number during consultation period","type":"phone","label":"Contact No. (From – To) / సంపƠ దింపు నంబర (నుండి – వరకు)","options":[],"required":null,"pdf_field":""},{"help":"Name of disease or disorder","type":"text","label":"Disease/ Disorder / వాƟధి / లోపం","options":[],"required":null,"pdf_field":""},{"help":"Hospital or doctor name","type":"text","label":"Name of Hospital/Doctor / హాసిƚటల / డాకƐ ర పేరు","options":[],"required":null,"pdf_field":""},{"help":"Hospital or doctor address","type":"text","label":"Address / చిరునామా","options":[],"required":null,"pdf_field":""},{"help":"Telephone number","type":"phone","label":"Tel. No. / ఫోన నంబర","options":[],"required":null,"pdf_field":""},{"help":"Registration or license number of hospital/doctor","type":"text","label":"Registration/ License No / రిజిసేƩ షన / లైసెనƧ్ నంబర","options":[],"required":null,"pdf_field":""},{"help":"Hospital admission date","type":"date","label":"Date of Admission / పƠ వేశ తేదీ","options":[],"required":null,"pdf_field":""},{"help":"Date of surgery if performed","type":"date","label":"Date of Operation (if any)/ ఆపరేషన తేది (ఉండితే)","options":[],"required":false,"pdf_field":""},{"help":"Hospital discharge date","type":"date","label":"Date of Discharge/ డిశాƊరƌ్ తేది","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Insurance Coverage Details","fields":[{"help":"Details of other insurance coverage","type":"text","label":"Details of Critical Insurance coverage/Mediclaim coverage of the Life Assured/ బీమా పొందిన వƟకిƕ కి సంబంధించిన పా ణాంతక / మెడికెƢ యిమ బీమా వివరాలు","options":[],"required":null,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No / పాలసీ నంబర","options":[],"required":null,"pdf_field":""},{"help":"Name of insurer","type":"text","label":"Insurer/ బీమా సంసƖ","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration & Authorization","fields":[{"help":"Place and date of signing","type":"text","label":"Signed at/ సంతకం చేయబడింది (Place) on this/ దీనిపై (సƖ లం) Day of/ రోజు Month/ నెల Year/ సంవతƧరం","options":[],"required":true,"pdf_field":""},{"help":"Select type of coverage","type":"choice","label":"Nature of coverage (i.e. Mediclaim or CI)/ కవరేజ సƤభావం (ఉదా: మెడికెƢ యిమ లేదా సి.ఐ.)","options":["Mediclaim","CI"],"required":true,"pdf_field":""},{"help":"Effective date of coverage","type":"date","label":"Effective Date/ పƠ భావిత తేది","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Claimant / కెƢ యిమ దారుడి సంతకం","options":[],"required":true,"pdf_field":""},{"help":"Claimant's address","type":"text","label":"Address of the Claimant / కెƢ యిమ దారుడి చిరునామా","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness / సాక͚̀ దారు సంతకం","options":[],"required":true,"pdf_field":""},{"help":"Witness name","type":"text","label":"Name of witness / సాక͚̀ దారు పేరు","options":[],"required":true,"pdf_field":""},{"help":"Witness address","type":"text","label":"Address of witness/ సాక͚̀ దారు చిరునామా","options":[],"required":true,"pdf_field":""},{"help":"Witness contact number","type":"phone","label":"Contact no. of witness/ సాక͚̀ దారు ఫోన","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vernacular Declaration","fields":[{"help":"Name of the witness who explained the form","type":"text","label":"Name of the Witness/ సాక͚̀ దారు పేరు","options":[],"required":true,"pdf_field":""},{"help":"Address of the witness","type":"text","label":"Address of the Witness/ సాక͚̀ దారు చిరునామా","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of the Witness / సాక͚̀ దారు సంతకం","options":[],"required":true,"pdf_field":""},{"help":"Witness contact number","type":"phone","label":"Contact No. of the Witness/ సాక͚̀ దారు ఫోన","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 in all respects.","Submission of this form does not constitute admission of insurance in force or waiver of rights by the company.","The claimant authorizes any doctor, hospital, medical professional, insurance support organization, employer, or other entity to provide information related to health, treatment, or employment 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/64-application-for-critical-illness-claim"}