{"id":78,"title":"APPLICATION FOR TERMINAL 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_Terminal%20Illness_Kannada.pdf","sha256":"320bf86244309a91efb069ed971c8d008ecbf8b09f605160e4b3005aa7eccb44","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for claiming terminal illness benefits under a life insurance policy 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.","The form must be witnessed by one of the following: Block Development Officer, Bank Manager of a Nationalized Bank with rubber stamp, Company Officer not below Manager rank, Gazetted Officer, Head Master/Principal of a Govt. School, Magistrate, or Notary Public.","Use clear and unambiguous answers.","Submit original investigation reports and discharge summary along with this form."],"title":"APPLICATION FOR TERMINAL ILLNESS CLAIM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Terminal Illness and Life Assured","fields":[{"help":"","type":"text","label":"Please state the specific terminal illness for which the claim is being made","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Immediate Cause of Admission into a hospital/Nature of complaint","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Diagnosis arrived at","options":[],"required":true,"pdf_field":""},{"help":"Date when terminal illness was diagnosed","type":"date","label":"Date of Diagnosis of terminal illness","options":[],"required":true,"pdf_field":""},{"help":"Provide full name and address of hospital(s) where treatment was received","type":"text","label":"Name and Address of the Hospital(s)","options":[],"required":true,"pdf_field":""},{"help":"Your insurance policy number","type":"text","label":"Policy No","options":[],"required":true,"pdf_field":""},{"help":"Age of the Life Assured in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Name of the Life Assured","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Address of the Life Assured","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Occupation of the Life Assured","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Office address of the Life Assured","type":"text","label":"Office Address","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Residence Telephone No. (with STD code)","options":[],"required":true,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":true,"pdf_field":""},{"help":"Name of the bank where claimant holds account","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Account number of the claimant","type":"text","label":"Bank Account No.","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","options":[],"required":true,"pdf_field":""},{"help":"Details of treatment provided","type":"text","label":"Treatment given","options":[],"required":true,"pdf_field":""},{"help":"List all medical tests and investigations done","type":"text","label":"Investigations done and tests conducted","options":[],"required":true,"pdf_field":""},{"help":"Provide full contact details of doctors and medical centers consulted","type":"text","label":"Name, address and Telephone numbers of the Doctor(s)/ Medical Centers consulted during the illness","options":[],"required":true,"pdf_field":""},{"help":"List doctors and illnesses treated 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","options":[],"required":true,"pdf_field":""},{"help":"Period for which illness lasted","type":"text","label":"Duration of Illness","options":[],"required":true,"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?","options":[],"required":true,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of the Doctor","options":[],"required":true,"pdf_field":""},{"help":"Doctor's address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Consultation period (from - to)","type":"text","label":"Period of Consultation","options":[],"required":true,"pdf_field":""},{"help":"Contact number during consultation period","type":"phone","label":"Contact No. (From – To)","options":[],"required":true,"pdf_field":""},{"help":"Name of disease or disorder","type":"text","label":"Disease/ Disorder","options":[],"required":true,"pdf_field":""},{"help":"Hospital or doctor name","type":"text","label":"Name of Hospital/Doctor","options":[],"required":true,"pdf_field":""},{"help":"Hospital or doctor's address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Telephone number","type":"phone","label":"Tel. No.","options":[],"required":true,"pdf_field":""},{"help":"Doctor or hospital registration/license number","type":"text","label":"Registration/ License No","options":[],"required":true,"pdf_field":""},{"help":"Hospital admission date","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Date of surgery if applicable","type":"date","label":"Date of Operation (if any)","options":[],"required":false,"pdf_field":""},{"help":"Hospital discharge date","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Provide details of any other insurance coverage","type":"text","label":"Details of Critical Insurance coverage/Mediclaim coverage of the Life Assured","options":[],"required":false,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurer","type":"text","label":"Insurer","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration and Authorization","fields":[{"help":"Place where form is signed","type":"text","label":"Signed at (Place)","options":[],"required":true,"pdf_field":""},{"help":"Day of signing","type":"number","label":"Day of","options":[],"required":true,"pdf_field":""},{"help":"Month of signing","type":"text","label":"Month","options":[],"required":true,"pdf_field":""},{"help":"Year of signing","type":"number","label":"Year","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"Claimant's address","type":"text","label":"Address of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness","options":[],"required":true,"pdf_field":""},{"help":"Name of the witness","type":"text","label":"Name of witness","options":[],"required":true,"pdf_field":""},{"help":"Witness address","type":"text","label":"Address of witness","options":[],"required":true,"pdf_field":""},{"help":"Witness contact number","type":"phone","label":"Contact no. of witness","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","options":[],"required":true,"pdf_field":""},{"help":"Address of the witness","type":"text","label":"Address of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of the Witness","options":[],"required":true,"pdf_field":""},{"help":"Witness contact number","type":"phone","label":"Contact No. of the Witness","options":[],"required":true,"pdf_field":""}],"filled_by":"witness"}],"deadlines":[],"applies_to":"Terminal 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 answers and statements given are true in all respects.","Submitting this form does not mean the company admits insurance was in force or waives any rights.","Authorization is given to doctors, hospitals, insurers, and other entities to provide information about the Life Insured's health, treatment, and related details including sensitive information such as mental illness, drug/alcohol use, HIV/AIDS, and sexually transmitted diseases.","A photocopy of this authorization is as valid as the original.","For illiterate claimants, the form contents have been explained in a language understood and the claimant has affixed thumb impression in presence of a witness."],"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/78-application-for-terminal-illness-claim"}