{"id":650,"title":"Claim Form A - Critical Illness","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-a-critical-illness-new.pdf","sha256":"c7929e822400503ccc37da87361fb0a2f64c5ef0015f91974cb5e64f43a7e415","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the claimant to file a critical illness insurance claim under the policy. The claimant or the life assured fills this form.","notes":["Fill all answers in BLOCK LETTERS without dots or dashes.","Attach a cancelled cheque leaf for bank account verification.","If space provided is inadequate, attach annexures.","Beware of spurious phone calls and fraudulent offers; lodge police complaint if received."],"title":"Claim Form A - Critical Illness","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Life Assured and Policy Details","fields":[{"help":"Enter the date of filling the form in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter full name in BLOCK LETTERS without dots or dashes","type":"text","label":"Name of the Life Assured","options":[],"required":true,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"Enter the name of the policy","type":"text","label":"Policy Name","options":[],"required":true,"pdf_field":""},{"help":"List other policies with Policy Number, Date of Commencement, Sum Assured","type":"table","label":"Mention full particulars of all other policies held by the Life Assured with other Companies.","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Illness and Diagnosis Details","fields":[{"help":"Enter the date when illness was diagnosed","type":"date","label":"Date of diagnosis/illness","options":[],"required":true,"pdf_field":""},{"help":"Describe the diagnosis details","type":"text","label":"Details of diagnosis","options":[],"required":true,"pdf_field":""},{"help":"Describe the nature of your illness complaint","type":"text","label":"What was the nature of complaint?","options":[],"required":true,"pdf_field":""},{"help":"Provide full contact details of the doctor","type":"text","label":"Name, address and telephone number of the Doctor who diagnosed/treated your illness initially","options":[],"required":true,"pdf_field":""},{"help":"Provide full hospital name and address","type":"text","label":"Name, address of the Hospital","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details of Life Assured","fields":[{"help":"Enter the name of your bank","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code of your bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Enter branch name of your bank","type":"text","label":"Branch Name","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Correspondence Address / Usual Place of Residence","fields":[{"help":"Enter full correspondence address including flat no., building, road, landmark, district, city, state, pin code","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":""},{"help":"Enter email address if available","type":"email","label":"Email Address","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Hospitalization Details","fields":[{"help":"Enter hospital admission date if applicable","type":"date","label":"Date of Admission","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital discharge date if applicable","type":"date","label":"Date of Discharge","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Documents Enclosed","fields":[{"help":"Tick all documents you are submitting with this claim form","type":"checkbox","label":"I am enclosing herewith:","options":["Policy document","Original reports including all investigation reports","Doctor/hospital certificate/s","Cancelled cheque & bank passbook/bank statement","Other"],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration and Signatures","fields":[{"help":"Witness must sign here","type":"signature","label":"Signature of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Date of witness signature","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Life Assured must sign here","type":"signature","label":"Signature of the Life Assured","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of the witness","type":"text","label":"Name of the Witness","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant and witness"},{"title":"Declaration by the person completing this claim form","fields":[{"help":"Enter full name of the person completing the form if not claimant","type":"text","label":"Name of Declarant","options":[],"required":true,"pdf_field":""},{"help":"Enter full address of declarant","type":"text","label":"Address of Declarant","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number of declarant","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":""},{"help":"Enter email address of declarant","type":"email","label":"Email Address","options":[],"required":false,"pdf_field":""},{"help":"Declarant must sign here","type":"signature","label":"Signature of Declarant","options":[],"required":true,"pdf_field":""}],"filled_by":"person completing form if not claimant"}],"deadlines":[],"applies_to":"Critical Illness claims","attachments":["Policy document","Original reports including all investigation reports","Doctor/hospital certificate/s","Cancelled cheque & bank passbook/bank statement","Other"],"declarations":["The statements in this claim form are true and correct to the best of the claimant's knowledge and belief.","If the claimant cannot read, write or speak English, the person completing the form declares that they have explained the contents and recorded the claimant's responses accurately."],"dropped_labels":2},"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/650-claim-form-a-critical-illness"}