{"id":88,"title":"Claim Form - Covid 19 Rider / હકફોમͮ – કોિવડ-૧૯ રાઇડર","purpose":"claim","insurer":{"slug":"bandhan-life-insurance","name":"Bandhan Life Insurance Limited"},"source_pdf":"https://www.bandhanlife.com/sites/default/files/asset/2026-04/COVID-19%20Rider%20Claim%20form_Gujarati.pdf","sha256":"5a310c0aac0d8e38b296b35ff71cdc09b3837daf33be507df4207df0a661d245","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for claiming the Covid-19 Rider benefit under a Bandhan Life insurance policy. It is to be filled by the claimant who is entitled to receive the policy monies.","notes":["Form must be filled in BLOCK letters.","Only the person entitled to receive policy monies shall fill and sign the form.","Rider benefit is payable only if policy is in force on date of hospitalization and other policy conditions are met.","Regulatory guidelines require payouts to be credited directly to bank account; attach self-attested cancelled cheque or bank passbook copy with pre-printed name.","Witness must be a person of local standing, notary, Class 1 Gazette Officer, Special Executive Magistrate, or lawyer.","If claimant signs in vernacular or uses thumb impression, witness must sign the vernacular declaration."],"title":"Claim Form - Covid 19 Rider / હકફોમͮ – કોિવડ-૧૯ રાઇડર","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claimant and Insured Details","fields":[{"help":"","type":"text","label":"City/ શહેર","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State / રાȂ","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pincode / િપનકોડ","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured name/ વીમાધારકનું નામ","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender/ Єલંગ","options":["Male/ પુ͗ ષ","Female/ મિહલા","Third Gender/ Ʃીજું Єલંગ"],"required":null,"pdf_field":""},{"help":"Use date format as per instructions","type":"date","label":"Date of birth/ જɐ તારીખ","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Complete address/ પૂણͯ સરનામું","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Certificate of insurance no./ વીમાની ƮમાણપƩ સંǖા","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile number with country code if applicable","type":"phone","label":"Mobile No/ મોબાઇલ નંબર","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Master policy no./ માˑર પોિલસી નંબર","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email/ ઇમેલ","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details","fields":[{"help":"Mandatory for payout processing","type":"text","label":"Bank Name/ બΌ કનું નામ","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code/ આઈએફએસસી કોડ","options":[],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No/ ખાતા નંબર","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Account Type/ ખાતા Ʈકાર","options":["Savings/ બચત","Current/ વતͯમાન"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"MICR code/ એમઆઈસીઆર કોડ","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Hospitalization Details","fields":[{"help":"","type":"text","label":"Name of hospital/ હોિ˗ટલનું નામ","options":[],"required":null,"pdf_field":""},{"help":"Full hospital address","type":"text","label":"Complete address of the hospital/ હોિ˗ટલનું સંપૂણͯ સરનામું","options":[],"required":null,"pdf_field":""},{"help":"Date format as per instructions","type":"date","label":"Date of admission/ દાખલ થવાની તારીખ","options":[],"required":null,"pdf_field":""},{"help":"Date format as per instructions","type":"date","label":"Date of discharge/ છૂટા પાડવાની તારીખ","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration & Authorization","fields":[{"help":"Sign or affix left thumb impression","type":"signature","label":"Signature/ Left thumb impression of claimant","options":[],"required":true,"pdf_field":""},{"help":"Date when Covid-19 was diagnosed","type":"date","label":"Date of diagnosis of Covid-19/ કોિવડ-૧૯ના િનદાનની તારીખ","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Witness Details and Declaration","fields":[{"help":"","type":"text","label":"Name of witness / સાǏીનું નામ","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of witness/ સાǏીનું સરનામું","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of witness/  સાǏીની સહી","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact no. of witness/ સાǏીનો સંપકͯ નંબર","options":[],"required":null,"pdf_field":""},{"help":"Witness must be one of these persons","type":"choice","label":"Witness declaration to be signed by any of these / સાǎી ͜હેરખબર નીચેના પૈકી કોઈ એક ʭિǃ Ⱥારા સાઇન કરવામͩ આવવી ͟ ઈએ","options":["Person of local standing / ˔ાિનક Ʈિતિˆત ʮિDŽ","Notary / નોટરી","Class 1 Gazette Officer / વગͯ ૧ના ગેઝેટેડ અિધકારી","Special Executive Magistrate / િવશેષ એિƿNjુિટવ મેિજˑΪેટ","Lawyer / વકીલ"],"required":null,"pdf_field":""}],"filled_by":"witness"}],"deadlines":[],"applies_to":"Covid-19 Rider claims under Bandhan Life insurance policies","attachments":["Claim form duly filled & signed / સાચવીને ભરેલું અને સહી કરેલું હકફોમͯ","Copy of Hospital discharge summary / હોિ˗ટલ િડːાજͯ સારͪ શની નકલ","Copy of Covid-19 test report & other lab reports / કોિવડ-૧૯ ટેˑ િરપોટͯ અને અɑ લેબ િરપોટͯની નકલ","KYC documents of claimant / દાવેદારના કેવાયસી દ˓ાવે͠","PAN or Form No 60 / પાન કાડͯ અથવા ફોમͯ નં. 60","Copy of any one of the following (Identity & address proof of claimant) / નીચેનામͪ થી કોઈ એકની નકલ (દાવેદારની ઓળખ અને સરનામાનો પુરાવો)","Valid Passport / માɑ પાસપોટͯ","Valid Driving License / માɑ ડΪ ાઇિવંગ લાઇસɔ","Voter’s Identity Card / મતદારે ઓળખપƩ (વોટર આઈ.ડી. કાડͯ)","Job Card issued by NREGA duly signed by an officer of State Government / રાȂ સરકારના અિધકારી Ȼારા સહી કરાયેલ એનઆરઇ͞","Proof of possession of Aadhar number (first 8 digits to be masked) in such a form as issued by the Unique Identification authority of India (means ‘Aadhar Card’) / આધાર નંબર (પહેલા 8 અંકો છુપાવવા પડશે) હોવાનો પુરાવો ભારતના િવિશ˅ ઓળખ અિધકારી (જેનો અથͯ 'આધાર કાડͯ' થાય છે) Ȼારા ͝રી કરાયેલ ફોમͯમͪ .","Copy of self-attested cancelled cheque bearing pre-printed name of beneficiary/Passbook copy of the claimant / લાભાથͽના િƮ-િƮɆેડ નામવાળી ˝Ʈમાિણત રદ થયેલી ચેકની નકલ / દાવેદારના પાસબુકની નકલ"],"declarations":["The claimant declares that all answers and statements are true in all respects.","Submitting this form or any supplemental form does not constitute admission by the company that insurance was in force or waiver of rights.","The claimant consents to Bandhan Life Insurance Ltd. obtaining all relevant records and conducting investigations as deemed fit.","Payment of claim amount shall discharge Bandhan Life Insurance Ltd. of its liability.","If claimant signs in vernacular or affixes thumb impression, a witness must sign a declaration confirming the claimant understood the form."],"dropped_labels":2},"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/88-claim-form-covid-19-rider"}