{"id":93,"title":"Claim Form - Covid 19 Rider / \f\f \f \f\f 19 \f\f\f\f\f","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_Kannada.pdf","sha256":"ae8c105f96f6503df59361d4353687d14ae48cba9857230339684eb68b46ee7e","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 the policy monies shall fill and sign the form.","Rider benefit is payable subject to policy being in force on the date of hospitalization and other policy conditions.","Regulatory guidelines require payouts to be directly credited to the beneficiary's bank account with a self-attested cancelled cheque or passbook copy.","If claimant signs in vernacular or affixes thumb impression, a witness must also sign the declaration.","Witness must be a person of local standing, Special Executive Magistrate, Notary, Lawyer, or Class 1 Gazette Officer."],"title":"Claim Form - Covid 19 Rider / \f\f \f \f\f 19 \f\f\f\f\f","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claimant Details and Required Documents","fields":[{"help":"Fill in the insured person's personal details including name, gender, date of birth, address, policy numbers, mobile and email.","type":"text","label":"Details of the Insured / \f\f\f\f\f\f\f\f\f\f\f","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Document Checklist","fields":[{"help":"Ensure the form is completely filled and signed by the claimant.","type":"checkbox","label":"Claim form duly filled & signed","options":[],"required":true,"pdf_field":""},{"help":"Attach a copy of the hospital discharge summary.","type":"attachment","label":"Copy of Hospital discharge summary","options":[],"required":true,"pdf_field":""},{"help":"Attach Covid-19 test report and other relevant lab reports.","type":"attachment","label":"Copy of Covid-19 test report & other lab reports","options":[],"required":true,"pdf_field":""},{"help":"Attach KYC documents such as PAN or Form 60 and identity & address proof.","type":"attachment","label":"KYC documents of claimant","options":[],"required":true,"pdf_field":""},{"help":"Attach a self-attested cancelled cheque or passbook copy for bank account verification.","type":"attachment","label":"Copy of self-attested cancelled cheque bearing pre-printed name of beneficiary/Passbook copy of the claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details","fields":[{"help":"Enter the name of the bank for claim payout.","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Enter the IFSC code of the bank branch.","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Enter the bank account number.","type":"text","label":"Account No","options":[],"required":true,"pdf_field":""},{"help":"Select the type of bank account.","type":"choice","label":"Account Type","options":["Savings","Current"],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Hospitalization Details","fields":[{"help":"Enter the hospital name where treatment was received.","type":"text","label":"Name of hospital","options":[],"required":true,"pdf_field":""},{"help":"Enter the full address of the hospital.","type":"text","label":"Complete address of the hospital","options":[],"required":true,"pdf_field":""},{"help":"Enter the date of hospital admission.","type":"date","label":"Date of admission","options":[],"required":true,"pdf_field":""},{"help":"Enter the date of hospital discharge.","type":"date","label":"Date of discharge","options":[],"required":true,"pdf_field":""},{"help":"Enter the MICR code of the hospital if available.","type":"text","label":"MICR code","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration & Authorization","fields":[{"help":"Sign or affix left thumb impression here.","type":"signature","label":"Signature/ Left thumb impression of claimant","options":[],"required":true,"pdf_field":""},{"help":"If claimant signs in vernacular or thumb impression, witness must sign and provide name.","type":"text","label":"Name of witness","options":[],"required":false,"pdf_field":""},{"help":"Witness declaration if claimant signs in vernacular or thumb impression.","type":"text","label":"Vernacular Declaration","options":[],"required":false,"pdf_field":""},{"help":"Enter the date when Covid-19 was diagnosed.","type":"date","label":"Date of diagnosis of Covid-19","options":[],"required":true,"pdf_field":""},{"help":"Provide address of the witness.","type":"text","label":"Address of witness","options":[],"required":false,"pdf_field":""},{"help":"Witness must sign here.","type":"signature","label":"Signature of witness","options":[],"required":false,"pdf_field":""},{"help":"Provide contact number of the witness.","type":"phone","label":"Contact no. of witness","options":[],"required":false,"pdf_field":""},{"help":"Witness must be one of the listed authorized persons.","type":"choice","label":"Witness declaration to be signed by any of these","options":["Person of local standing","Special Executive Magistrate","Notary","Lawyer","Class 1 Gazette Officer"],"required":false,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Covid-19 Rider claims under Bandhan Life insurance policies","attachments":["Copy of Hospital discharge summary","Copy of Covid-19 test report & other lab reports","KYC documents of claimant","PAN or Form No 60","Copy of any one of the following (Identity & address proof of claimant): Valid Passport, Valid Driving License, Voter’s Identity Card, Job Card issued by NREGA duly signed by an officer of State Government, Proof of possession of Aadhar number (first 8 digits masked)","Copy of self-attested cancelled cheque bearing pre-printed name of beneficiary/Passbook copy of the claimant"],"declarations":["The answers and statements given are true in all respects.","Furnishing this form or any supplemental form does not admit insurance in force or waive any rights or defenses.","Consent is given to Bandhan Life Insurance Ltd. to obtain all relevant records and conduct investigations as deemed fit.","Payment of claim amount shall discharge Bandhan Life Insurance Ltd.'s liability."],"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/93-claim-form-covid-19-rider-19"}