{"id":902,"title":"Critical Illness Claim Form","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Critical%20Illness%20Claim%20Form.pdf","sha256":"f26556e5e31a7840a4b98915c08b2ee740fcd1fc1ccc8a75c9879aeda93287c0","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim benefits under the Critical Illness Insurance Policy by providing details of the insured, insurance history, diagnosis, and bank account for claim settlement.","notes":["Fill the form in block letters.","Use dd-mm-yy format for dates.","Attach original bills and certificates as required.","The issue of this form is not to be taken as admission of liability."],"title":"Critical Illness Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"SECTION A - DETAILS OF PRIMARY INSURED","fields":[{"help":"Enter the policy number as allotted by the insurance company","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name (Surname, First name, Middle name)","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Include Street, City, State and Pin Code","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No:","options":[],"required":null,"pdf_field":""},{"help":"Complete e-mail address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID No","type":"text","label":"Company/ TPA ID No:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION B - DETAILS OF INSURANCE HISTORY","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Currently covered by any other Mediclaim/ Health Insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of commencement of first insurance without break:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the insurance company","type":"text","label":"If yes, Company Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter the total sum insured as per the policy","type":"amount","label":"Sum Insured (`):","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Have you been hospitalized in the last four years since inception of the contract?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION C - DETAILS OF INSURED PERSON","fields":[{"help":"Enter full name (Surname, First name, Middle name)","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Enter the sum insured","type":"amount","label":"Sum insured:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"CB (if any):","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option. If others, please specify","type":"choice","label":"Occupation:","options":["Service","Self Employed","Homemaker","Student","Retired","Other"],"required":null,"pdf_field":""},{"help":"Include Street, City, State and Pin Code","type":"text","label":"Address (if different from above):","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION D - DETAILS OF CLAIM","fields":[{"help":"Enter name of the covered disease contracted","type":"text","label":"Name of the disease contacted","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format; attach certificate from doctor confirming diagnosis","type":"date","label":"Date of Diagnosis made","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the institution diagnosing the disease","type":"text","label":"Name of the Institution giving the Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Describe the present condition of the insured","type":"text","label":"Present condition of the patient","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Previously covered by any other Mediclaim/ Health Insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the full name of the insurance company","type":"text","label":"If yes, Company Name:","options":[],"required":false,"pdf_field":""},{"help":"Tick the right option. If others, please specify","type":"choice","label":"Relationship to Primary Insured:","options":["Self","Spouse","Child","Father","Mother","Other"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION E - DETAILS OF ENCLOSERS","fields":[{"help":"Serial number of each document enclosed","type":"number","label":"Sl. No.","options":[],"required":null,"pdf_field":""},{"help":"Reference number of each document enclosed","type":"text","label":"Ref No.","options":[],"required":null,"pdf_field":""},{"help":"Date of issue of each document","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Name of the issuing authority of each document","type":"text","label":"Issued By","options":[],"required":null,"pdf_field":""},{"help":"Purpose of each document enclosed","type":"text","label":"Towards","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION F - DETAILS OF PRIMARY INSURED'S BANK ACCOUNT","fields":[{"help":"Enter the Permanent Account Number as allotted by the Income Tax department","type":"text","label":"PAN:","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank account number","type":"text","label":"Account Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank name along with the branch","type":"text","label":"Bank Name and Branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the beneficiary the cheque/DD should be made out to","type":"text","label":"Cheque/ DD Payable details:","options":[],"required":null,"pdf_field":""},{"help":"Enter the IFSC code of the bank branch","type":"text","label":"IFSC Code:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DECLARATION BY THE INSURED","fields":[{"help":"Enter date in dd-mm-yy format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the insured:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Critical Illness Insurance Policy claims","attachments":["Certificate from the doctor confirming the Diagnosis","All bills / receipts for the purpose of this claim","Supporting documents with respect to statements under Section D"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","If any false or untrue statement, suppression or concealment of any material fact is made, the right to claim reimbursement shall be forfeited.","I consent and authorize TPA / insurance company to seek necessary medical information/documents from any hospital/Medical Practitioner who attended the insured.","I declare that I have included all bills/receipts for this claim and will not make any supplementary claim except pre/post-hospitalization claims, if any."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/national-insurance/902-critical-illness-claim-form"}