{"id":67,"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_Malayalam.pdf","sha256":"c5eb02e7242269beb76f7847c242fc797d8e00a6a66e2a58ec5e287ffac853b7","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 with surgeon's report.","The vernacular declaration must be witnessed by an authorized person such as a Block Development Officer, Bank Manager, Company Officer, Gazetted Officer, Head Master/Principal, Magistrate, Notary Public.","Use clear and unambiguous answers."],"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/ േപര്","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address/ വിലാസം","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation/ െതാഴിൽ","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Office Address/ ഓഫീസിെ¾ വിലാസം","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Residence Telephone No. (with STD code)/ േഫാൺ ന›ർ - െറസിഡൻസ് (STD േകാഡ് സഹിതം)","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No./ െമാൈബൽ ന›ർ","options":[],"required":true,"pdf_field":""},{"help":"Specify the illness","type":"text","label":"Please state the specific critical illness for which the claim is being made/ െ£യിം െച´Ê” ്രകി¨ി{ൽ േരാഗം വÂ|മാ{ുക","options":[],"required":true,"pdf_field":""},{"help":"Reason for hospital admission","type":"text","label":"Immediate Cause of Admission into a hospital/Nature of complaint / ആശുപ്രതിയിേല{് ്രപേവശി¬ി¦തിെ¾ അടിയ–ര കാരണവും / പരാതി","options":[],"required":true,"pdf_field":""},{"help":"Diagnosis or surgery details","type":"text","label":"Diagnosis arrived at/Surgery performed / നടിയ പരിേശാധന / ശസ്്രത്രകിയ","options":[],"required":true,"pdf_field":""},{"help":"Date of diagnosis or surgery","type":"date","label":"Date of Diagnosis of illness/ Surgery / േരാഗനിർണയ തീയതി / ശസ്്രത്രകിയ","options":[],"required":true,"pdf_field":""},{"help":"Hospital name and address","type":"text","label":"Name and Address of the Hospital(s) / ആശുപ്രതിയുെട േപര്, വിലാസം","options":[],"required":true,"pdf_field":""},{"help":"Policy number","type":"text","label":"Policy No / േപാളിസി ന›ർ","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age/ ്രപായം","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/ ബാ}ിെ¾ േപര്","options":[],"required":true,"pdf_field":""},{"help":"Account number of claimant","type":"text","label":"Bank Account No./ അ{ൗŒ് ന›ർ","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Treatment and Medical Consultation","fields":[{"help":"Date when treatment started","type":"date","label":"Date of commencement of treatment/ ചികിത്സ ആരംഭി¦ തീയതി","options":[],"required":null,"pdf_field":""},{"help":"Details of treatment provided","type":"text","label":"Treatment given/ നൽകിയ ചികിത്സ","options":[],"required":null,"pdf_field":""},{"help":"List investigations and tests done","type":"text","label":"Investigations done and tests conducted/ നടിയ പരിേശാധനകളÊം െട»ുകളÊം","options":[],"required":null,"pdf_field":""},{"help":"Provide contact details of doctors/medical centers consulted","type":"text","label":"Please state the Name, address and Telephone numbers of the Doctor(s)/ Medical Centers consulted during the illness/ രോഗകാലത്ത് ഡോക്ടർമാരുടെയും മെഡിക്കൽ സെന്ററുകളുടെയും പേര്, വിലാസം, ഫോൺ നമ്പറുകൾ","options":[],"required":null,"pdf_field":""},{"help":"Doctors consulted in last 3 years and related illnesses","type":"text","label":"Name & addresses of the Doctors who treated you during the last three years & the illnesses for which the treatment was availed./ കഴിഞ്ഞ മൂന്നു വർഷമായി നിന്നുള്ള ചികിത്സയിൽ ഡോക്ടർമാരുടെ പേര്, വിലാസം, ചികിത്സ സ്വീകരിച്ച രോഗങ്ങൾ","options":[],"required":null,"pdf_field":""},{"help":"Period of illness","type":"text","label":"Duration of Illness/ രോഗം അനുഭവിച്ച സമയപരിധി","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?/ ലൈഫ് അഷ്യൂർഡ് ആദ്യം രോഗം അനുഭവിച്ചത് / ലക്ഷണങ്ങൾ കണ്ടത് എപ്പോൾ?","options":[],"required":null,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of the Doctor / ഡോക്ടറുടെ പേര്","options":[],"required":null,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address / വിലാസം","options":[],"required":null,"pdf_field":""},{"help":"Consultation period (from-to)","type":"text","label":"Period of Consultation / ചികിത്സാ കാലയളവ്","options":[],"required":null,"pdf_field":""},{"help":"Contact number with dates","type":"phone","label":"Contact No. (From – To) / ഫോൺ നമ്പർ (തീയതി മുതൽ തീയതിവരെ)","options":[],"required":null,"pdf_field":""},{"help":"Name of disease or disorder","type":"text","label":"Disease/ Disorder / രോഗം / അസാധാരണത","options":[],"required":null,"pdf_field":""},{"help":"Hospital or doctor name","type":"text","label":"Name of Hospital/Doctor / ആശുപത്രി / ഡോക്ടറുടെ പേര്","options":[],"required":null,"pdf_field":""},{"help":"Hospital or doctor address","type":"text","label":"Address / വിലാസം","options":[],"required":null,"pdf_field":""},{"help":"Telephone number","type":"phone","label":"Tel. No. / ഫോൺ നമ്പർ","options":[],"required":null,"pdf_field":""},{"help":"Registration or license number","type":"text","label":"Registration/ License No / രജിസ്ട്രേഷൻ / ലൈസൻസ് നമ്പർ","options":[],"required":null,"pdf_field":""},{"help":"Hospital admission date","type":"date","label":"Date of Admission / പ്രവേശി¦ തീയതി","options":[],"required":null,"pdf_field":""},{"help":"Date of surgery if performed","type":"date","label":"Date of Operation (if any)/ ശസ്്രത്രകിയയുടെ തീയതി (ഉെŒ}ിൽ)","options":[],"required":false,"pdf_field":""},{"help":"Hospital discharge date","type":"date","label":"Date of Discharge/ ഡിസ്ചാർജി തീയതി","options":[],"required":null,"pdf_field":""},{"help":"Details of other insurance coverage","type":"text","label":"Details of Critical Insurance coverage/Mediclaim coverage of the Life Assured/ ലൈഫ് അഷ്യൂർഡ് ക്രിറ്റിക്കൽ ഇൻഷുറൻസ് കവറേജ്/മെഡിക്ലെയിം കവറേജ് വിശദാംശങ്ങൾ","options":[],"required":null,"pdf_field":""},{"help":"Policy number of other coverage","type":"text","label":"Policy No / പോളിസി നമ്പർ","options":[],"required":false,"pdf_field":""},{"help":"Name of insurer","type":"text","label":"Insurer/ ഇൻഷുറൻസ് കമ്പനി","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration & Authorization","fields":[{"help":"Place and date of signing","type":"text","label":"Signed at/ ഒ¬ി¨ത് (Place) on this/ ഇതിൽ (സ്ഥലം) Day of/ ദിവസം Month/ മാസം Year/ വർഷം","options":[],"required":true,"pdf_field":""},{"help":"Type of insurance coverage","type":"text","label":"Nature of coverage (i.e. Mediclaim or CI)/ കവറേജ് സ്വഭാവം (ഉദാ: മെഡിക്ലെയിം അല്ലെങ്കിൽ സി.ഐ.)","options":[],"required":null,"pdf_field":""},{"help":"Effective date of coverage","type":"date","label":"Effective Date/ പ്രാബല്യത്തിൽ തീയതി","options":[],"required":null,"pdf_field":""},{"help":"Claimant's signature","type":"signature","label":"Signature of the Claimant / അവകാശവാദിയുടെ ഒപ്പ്","options":[],"required":true,"pdf_field":""},{"help":"Claimant's address","type":"text","label":"Address of the Claimant / അവകാശവാദിയുടെ വിലാസം","options":[],"required":true,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Signature of Witness / സാക്ഷിയുടെ ഒപ്പ്","options":[],"required":true,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of witness / സാക്ഷിയുടെ പേര്","options":[],"required":true,"pdf_field":""},{"help":"Address of witness","type":"text","label":"Address of witness/ സാക്ഷിയുടെ വിലാസം","options":[],"required":true,"pdf_field":""},{"help":"Phone number of witness","type":"phone","label":"Contact no. of witness/ സാക്ഷിയുടെ ഫോൺ","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vernacular Declaration","fields":[{"help":"Name of the person explaining the form","type":"text","label":"Name of the Witness/ സാക്ഷിയുടെ പേര്","options":[],"required":true,"pdf_field":""},{"help":"Address of the witness","type":"text","label":"Address of the Witness/ സാക്ഷിയുടെ വിലാസം","options":[],"required":true,"pdf_field":""},{"help":"Signature of the witness","type":"signature","label":"Signature of the Witness / സാക്ഷിയുടെ ഒപ്പ്","options":[],"required":true,"pdf_field":""},{"help":"Phone number of the witness","type":"phone","label":"Contact No. of the Witness/ സാക്ഷിയുടെ ഫോൺ","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 that submitting this form does not mean the company admits insurance was in force or waives any rights.","The claimant authorizes any doctor, hospital, insurance company, or other entity to provide information about the insured's health, treatment, and related details to Bandhan Life Insurance Ltd.","A photocopy of this authorization is as valid as the original.","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/67-application-for-critical-illness-claim"}