{"id":640,"title":"Claim Form B - Medical Attendant Certificate","purpose":"claim","insurer":{"slug":"indusind-nippon-life-insurance","name":"IndusInd Nippon Life Insurance Company Limited"},"source_pdf":"https://www.indusindnipponlife.com/documents/34625/224924/claim-form-b-medical-attendant-certificate.pdf","sha256":"c5c5eee89133b50d8f33143f1846790d5e4ae01363dcf121590c06344a042a55","pages":1,"collected":"2026-10-17","instructions":{"about":"This form is to be filled in by the last treating doctor to provide medical details and certification for a claim related to the life assured.","notes":["All answers to be in Block Letters with no dots and dashes.","Beware of spurious phone calls and fraudulent offers.","Use original documents for enclosures."],"title":"Claim Form B - Medical Attendant Certificate","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Patient and Policy Details","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Write in block letters, no dots or dashes","type":"text","label":"Name of the Life Assured","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Age of the Life Assured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Correspondence Address/ Usual place of residence","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"EMAIL ADDRESS","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"MOBILE","options":[],"required":null,"pdf_field":""}],"filled_by":"Last Treating Doctor"},{"title":"Hospital/Clinic Details","fields":[{"help":"","type":"text","label":"Name and Address of the Hospital/Clinic","options":[],"required":null,"pdf_field":""},{"help":"Telephone STD/ISD code","type":"number","label":"STD ISD Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"EMAIL ADDRESS","options":[],"required":null,"pdf_field":""}],"filled_by":"Last Treating Doctor"},{"title":"Medical Details","fields":[{"help":"","type":"text","label":"What was the diagnosis?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Direct Cause(s) of Illness","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"What was the nature of complaint?","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"What was the history reported to you at the time of consultation?","options":[],"required":null,"pdf_field":""},{"help":"Name and relationship","type":"text","label":"By whom was it reported? (Mention Name & Relationship to the Patient)","options":[],"required":null,"pdf_field":""},{"help":"Specify years, months, days","type":"text","label":"How long has he/she been suffering from the illness?","options":[],"required":null,"pdf_field":""},{"help":"List tests and results","type":"text","label":"Were any tests conducted? If so, mention the tests and findings of the tests","options":[],"required":null,"pdf_field":""},{"help":"Date and time (HH:MM)","type":"date","label":"Date and Time of Admission","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Admission No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"What was the condition of the patient at the time of Discharge?","options":[],"required":null,"pdf_field":""}],"filled_by":"Last Treating Doctor"},{"title":"Enclosures","fields":[{"help":"Tick applicable and specify if 'Other'","type":"checkbox","label":"Enclosures","options":["Attested copy of investigation reports/hospital reports (case summary)","Discharge Summary","Other, if any"],"required":null,"pdf_field":""}],"filled_by":"Last Treating Doctor"},{"title":"Certification and Signature","fields":[{"help":"DD/MM/YYYY","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Doctor","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Attending Doctor","options":[],"required":null,"pdf_field":""},{"help":"Stamp or seal of hospital/clinic","type":"signature","label":"Hospital/Clinic Seal","options":[],"required":null,"pdf_field":""}],"filled_by":"Last Treating Doctor"}],"deadlines":[],"applies_to":"","attachments":["Attested copy of investigation reports/hospital reports (case summary)","Discharge Summary","Other, if any"],"declarations":["The particulars are furnished on the basis of the records maintained by the Hospital/Clinic."],"dropped_labels":3},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Claims Department, Office no. 701 & 702, 7th floor, Silver Metropolis, Off Western Express Highway, Goregaon East, Mumbai – 400063","label":"Claims Department postal address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.indusindnipponlife.com/claims","quote":"nearest\nINLIC branch\nfor in-person assistance.\nEmail scanned documents at\nclaims@indusindnipponlife.com\n.\nCourier to\n: Claims Department, Office no. 701 & 702, 7th floor, Silver Metropolis, Off Western Express Highway, Goregaon East, Mumbai – 400063.\nIn case of assistance, contact us on\n1800 102 3330\nor email us on\ncustomerservice@indusindnipponlife.com\nTrack A Claim","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"claims@indusindnipponlife.com","label":"Claims Department email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.indusindnipponlife.com/claims","quote":"ou Can Register your claim easily:\nVisit your nearest\nINLIC branch\nfor in-person assistance.\nEmail scanned documents at\nclaims@indusindnipponlife.com\n.\nCourier to\n: Claims Department, Office no. 701 & 702, 7th floor, Silver Metropolis, Off Western Express Highway, Gore","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 102 3330","label":"Claims Helpline","level":null,"hours":null,"applies_to":"all","source_url":"https://www.indusindnipponlife.com/claims","quote":"r, Silver Metropolis, Off Western Express Highway, Goregaon East, Mumbai – 400063.\nIn case of assistance, contact us on\n1800 102 3330\nor email us on\ncustomerservice@indusindnipponlife.com\nTrack A Claim\nFile a Claim\nLiving Benefits / Rider Claims\nGet the","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/indusind-nippon-life-insurance/640-claim-form-b-medical-attendant-certificate"}