{"id":82,"title":"APPLICATION FOR TERMINAL ILLNESS CLAIM / চূড়াȈ অসুɴতার দািব সংƔাȈ আেবদনপǭ","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_Bengali.pdf","sha256":"ae0da48e0a3c7a76c75d83fdd77d85fac159f4230861e0aa09008ea6feb50d9a","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.","notes":["All fields under 'Information about the Life Assured' and 'Bank Account Details' sections are mandatory.","The claimant must be the holder of the bank account provided.","Submit original investigation reports and discharge summary with operating surgeon's report and any other related reports.","The form must be witnessed by one of the specified authorized persons.","For illiterate claimants, the vernacular declaration must be completed by a witness unconnected with the company whose identity can be easily established."],"title":"APPLICATION FOR TERMINAL ILLNESS CLAIM / চূড়াȈ অসুɴতার দািব সংƔাȈ আেবদনপǭ","submit":{"to":"Bandhan Life Insurance Ltd","how":"","address":""},"purpose":"claim","sections":[{"title":"Information about the Life Assured","fields":[{"help":"","type":"text","label":"Policy No / পিলিস নȼর","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name/ নাম","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address/ ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation/ েপশা","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Office Address/ অিফেসর ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Residence Telephone No. (with STD code)/ বািড়র েটিলেফান নȼর (এস˘িড েকাডসহ)","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No./ েমাবাইল নȼর","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Bank Account Details","fields":[{"help":"Claimant must be the account holder","type":"text","label":"Bank Name/ বঁাংেকর নাম","options":[],"required":true,"pdf_field":""},{"help":"Claimant must be the account holder","type":"text","label":"Bank Account No./ অঁাকাউȄ নȼর","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Information about the Terminal Illness for which the claim is being made","fields":[{"help":"Specify the terminal illness","type":"text","label":"Please state the specific terminal illness for which the claim is being made / েয িনিদঁɢ চূড়াȉ অসুɵতার জনঁ দািব করা হেƺ, অনুƩহ কের েস˘ উেɕখ করুন","options":[],"required":true,"pdf_field":""},{"help":"State reason for hospital admission","type":"text","label":"Immediate Cause of Admission into a hospital/ Nature of complaint / হাসপাতােল ভিতঁ হওয়ার তাˁƘিণক কারণ / অিভেযােগর Ȣকৃিত","options":[],"required":true,"pdf_field":""},{"help":"Diagnosis of the terminal illness","type":"text","label":"Diagnosis arrived at / িনণ̅ ত েরাগ","options":[],"required":true,"pdf_field":""},{"help":"Date when terminal illness was diagnosed","type":"date","label":"Date of Diagnosis of terminal illness / চূড়াȉ অসুɵতার িনণ˿েয়র তািরখ","options":[],"required":true,"pdf_field":""},{"help":"Hospital(s) where treatment was received","type":"text","label":"Name and Address of the Hospital(s) / হাসপাতাল(Ơিল)-এর নাম ও ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age/ বয়স","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"In Years/ বছের","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Treatment and Medical Details","fields":[{"help":"Start date of treatment","type":"date","label":"Date of commencement of treatment/ িচিকৎসা ɖরুর তািরখ","options":[],"required":true,"pdf_field":""},{"help":"Details of treatment provided","type":"text","label":"Treatment given/ ȢদǨ িচিকৎসা","options":[],"required":true,"pdf_field":""},{"help":"List of investigations and tests done","type":"text","label":"Investigations done and tests conducted/ কৃত তদȉ ও সȸȕ পরীƘাসমূহ","options":[],"required":true,"pdf_field":""},{"help":"Doctors or medical centers consulted during illness","type":"text","label":"Please state the Name, address and Telephone numbers of the Doctor(s)/ Medical Centers consulted during the illness/অনুƩহ কের েরাগ চলাকালীন পরামশ˿ েনওয়া িচিকৎসক(েদর) / িচিকৎসা েকȐƠেলার নাম, ˙কানা ও েটিলেফান নȼর উেɕখ করুন।","options":[],"required":true,"pdf_field":""},{"help":"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./গত িতন বছের আপনােক িচিকৎসা Ȣদানকারী িচিকৎসকেদর নাম ও ˙কানা এবং েযসব েরােগর জনঁ িচিকৎসা েনওয়া হেয়েছ, েসƠেলার িববরণ িদন।","options":[],"required":true,"pdf_field":""},{"help":"Duration of the illness","type":"text","label":"Duration of Illness/ অসুɵতার সময়কাল","options":[],"required":true,"pdf_field":""},{"help":"Date or time when symptoms first appeared","type":"text","label":"When did the Life Assured first complain of the illness or experience symptoms of the same?/ লাইফ অঁািসউড˿ Ȣথম কেব এই অসুɵতার অিভেযাগ কেরন বা এর উপসগ˿ অনুভব কেরন?","options":[],"required":true,"pdf_field":""},{"help":"Name of hospital or doctor","type":"text","label":"Name of Hospital/Doctor / হাসপাতাল/িচিকৎসেকর নাম","options":[],"required":true,"pdf_field":""},{"help":"Address of hospital or doctor","type":"text","label":"Address / ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Telephone number","type":"phone","label":"Tel. No. / েটিলেফান নȼর","options":[],"required":true,"pdf_field":""},{"help":"Registration or license number of doctor/hospital","type":"text","label":"Registration/ License No / িনবȒন / লাইেসș নȼর","options":[],"required":false,"pdf_field":""},{"help":"Date of hospital admission","type":"date","label":"Date of Admission / ভিতঁর তািরখ","options":[],"required":true,"pdf_field":""},{"help":"Date of operation if performed","type":"date","label":"Date of Operation (if any)/ অেɳাপচােরর তািরখ (যিদ হেয় থােক)","options":[],"required":false,"pdf_field":""},{"help":"Date of hospital discharge","type":"date","label":"Date of Discharge/ ছাড়পেǮর তািরখ","options":[],"required":true,"pdf_field":""},{"help":"Name of treating doctor","type":"text","label":"Name of the Doctor / িচিকৎসেকর নাম","options":[],"required":true,"pdf_field":""},{"help":"Address of treating doctor","type":"text","label":"Address / ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Consultation period with doctor","type":"text","label":"Period of Consultation / পরামেশ˿র সময়কাল","options":[],"required":true,"pdf_field":""},{"help":"Contact number during consultation period","type":"phone","label":"Contact No. (From – To) / েযাগােযাগ নȼর (হেত – পয˿ȉ)","options":[],"required":true,"pdf_field":""},{"help":"Disease or disorder treated","type":"text","label":"Disease/ Disorder / এরাগ / বঁািধ","options":[],"required":true,"pdf_field":""},{"help":"Details of any critical illness or mediclaim coverage","type":"text","label":"Details of Critical Insurance coverage/Mediclaim coverage of the Life Assured/ বীমাকৃত বঁিƐর Ơরুতর েরাগ িবমা/েমিডেƖম কভােরজ সȸিকঁত িববরণ","options":[],"required":false,"pdf_field":""},{"help":"Policy number of other insurance if any","type":"text","label":"Policy No / পিলিস নȼর","options":[],"required":false,"pdf_field":""},{"help":"Name of insurer for other coverage","type":"text","label":"Insurer/ বীমাকারী","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Declaration & Authorization","fields":[{"help":"","type":"signature","label":"Signature of the Claimant / দািবদােরর ɻাƘর","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address of the Claimant / দািবদােরর ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Place and date of signing","type":"text","label":"Signed at/ ɻাƘিরত ɵান (Place) on this/ (ɵান) এই তািরেখ","options":[],"required":true,"pdf_field":""},{"help":"Day of signing","type":"number","label":"Day of/ িদেনর","options":[],"required":true,"pdf_field":""},{"help":"Month of signing","type":"text","label":"Month/ মাস","options":[],"required":true,"pdf_field":""},{"help":"Year of signing","type":"number","label":"Year/ বছর","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness / সাƘীর ɻাƘর","options":[],"required":true,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of witness / সাƘীর নাম","options":[],"required":true,"pdf_field":""},{"help":"Address of witness","type":"text","label":"Address of witness/ সাƘীর ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Contact number of witness","type":"phone","label":"Contact no. of witness/ সাƘীর েযাগােযাগ নȼর","options":[],"required":true,"pdf_field":""},{"help":"Select one witness category","type":"choice","label":"The form must be witnessed by any one of the following / ফম˾˗ িনȶিলিখত েয েকােনা একজন সাƗীর Ǿারা সাƗঁȡাț হেত হেব:","options":["Block Development Officer / Ȳক উȕয়ন আিধকািরক","A Bank Manager of a Nationalized Bank with Rubber Stamp / রাবার ɯঁাȸসহ এক˘ জাতীয়কৃত বঁাংেকর মঁােনজার","An Officer of the Company not below the rank of Manager / েকাȸািনর মঁােনজার পদময˿াদার িনেচ নয় এমন েকােনা অিফসার","A Gazetted Officer / একজন েগেজেটড অিফসার","Head Master / Principal of a Govt. School / সরকাির িবদঁালেয়র Ȣধান িশƘক / িȢিșপাল","A Magistrate / একজন মঁািজেɰট","Notary Public / েনাটাির পাবিলক"],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vernacular Declaration","fields":[{"help":"Name of witness certifying explanation to claimant","type":"text","label":"Name of the Witness/ সাƘীর নাম","options":[],"required":true,"pdf_field":""},{"help":"Address of witness","type":"text","label":"Address of the Witness/ সাƘীর ˙কানা","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of the Witness / সাƘীর ɻাƘর","options":[],"required":true,"pdf_field":""},{"help":"Contact number of witness","type":"phone","label":"Contact No. of the Witness/ সাƘীর েযাগােযাগ নȼর","options":[],"required":true,"pdf_field":""}],"filled_by":"witness"}],"deadlines":[],"applies_to":"","attachments":["All investigation reports (E.g.: Blood reports, ECG, Angiography, Histopathology etc.)","Discharge summary from Hospital with the 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 admit any insurance or waive any rights by the company.","The claimant authorizes any doctor, hospital, insurance support organization, employer, or other entity to provide Bandhan Life Insurance Ltd with any information related to the health, treatment, or finances of the life insured, including sensitive information such as mental illness, drug use, alcohol use, HIV/AIDS, and sexually transmitted diseases.","A Photostat copy of this authorization is as valid as the original.","The form must be witnessed by an authorized person from the specified categories.","In case of an illiterate claimant, a witness must certify that the form contents were explained in a language understood by the claimant and that the claimant affixed their thumb impression in the witness's presence."],"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/82-application-for-terminal-illness-claim-i-i-o"}