{"id":94,"title":"Claim Form - Covid 19 Rider / േകാവിഡ് 19 ൈറഡറിനായുÔ െ£യിം േഫാം","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_Malayalam.pdf","sha256":"f704167e20d80fece2bf8b22aad9f9d6bcab3133e5b10f43b3e6762c40283a5b","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 only if the policy is in force on the date of hospitalization and other policy conditions are met.","Regulatory guidelines require payouts to be credited directly to the beneficiary's bank account; attach self-attested cancelled cheque or bank passbook copy.","If claimant signs with thumb impression or in vernacular, witness declaration is mandatory."],"title":"Claim Form - Covid 19 Rider / േകാവിഡ് 19 ൈറഡറിനായുÔ െ£യിം േഫാം","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claimant Details and Document Checklist","fields":[{"help":"Fill in the insured person's details as requested","type":"text","label":"Details of the Insured / ഇൻഷുറുഡ് വÂ|ിയുെട വിവര~ൾ","options":[],"required":null,"pdf_field":""},{"help":"Enter city of insured","type":"text","label":"City/ നഗരം","options":[],"required":null,"pdf_field":""},{"help":"Enter state of insured","type":"text","label":"State / സംžാനം","options":[],"required":null,"pdf_field":""},{"help":"Enter pincode","type":"number","label":"Pincode / പിൻ േകാഡ്","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of insured","type":"text","label":"Insured name/ ഇൻഷുറ്ട് വÂ|ിയുെട േപര്","options":[],"required":null,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender/ ലിംഗം","options":["Male/ പുരുഷൻ","Female/ സ്്രതീ","Third Gender/ മൂ”ാം ലിംഗം"],"required":null,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of birth/ ജനനി´തി","options":[],"required":null,"pdf_field":""},{"help":"Enter full address","type":"text","label":"Complete address/ പൂർª വിലാസം","options":[],"required":null,"pdf_field":""},{"help":"Enter insurance certificate number","type":"text","label":"Certificate of insurance no./ ഇൻഷുറൻസ് സർ¨ിഫി{µ് ന›ർ","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No/ െമാൈബൽ ന›ർ","options":[],"required":null,"pdf_field":""},{"help":"Enter master policy number","type":"text","label":"Master policy no./ മാ»ർ േപാളിസി ന›ർ","options":[],"required":null,"pdf_field":""},{"help":"Enter email address (optional)","type":"email","label":"Email/ ഇെമയിൽ ഐഡി","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details","fields":[{"help":"Enter bank name for payout","type":"text","label":"Bank Name/ ബാ}ിെ¾ േപര്","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code/ ഐ.എഫ്.എസ്.സി. േകാഡ്","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account No/ അ{ൗŒ് ന›ർ","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account Type/ അ{ൗŒ് തരം","options":["Savings/ േസവിംഗ്സ്","Current/ കറ¿"],"required":true,"pdf_field":""},{"help":"Enter MICR code if available","type":"text","label":"MICR code/ MICR േകാഡ്","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Hospitalization Details","fields":[{"help":"Enter hospital name where admitted","type":"text","label":"Name of hospital/ ആശുപ്രതിയുെട േപര്","options":[],"required":null,"pdf_field":""},{"help":"Enter full hospital address","type":"text","label":"Complete address of the hospital/ ആശുപ്രതിയുെട മുഴÕവൻ വിലാസം","options":[],"required":null,"pdf_field":""},{"help":"Enter admission date","type":"date","label":"Date of admission/ ്രപേവശന തീയതി","options":[],"required":null,"pdf_field":""},{"help":"Enter admission time","type":"text","label":"Time/ സമയം","options":[],"required":false,"pdf_field":""},{"help":"Enter discharge date","type":"date","label":"Date of discharge/ ഡിസ്ചാർജ് തീയതി","options":[],"required":null,"pdf_field":""},{"help":"Enter discharge time","type":"text","label":"Time/ സമയം","options":[],"required":false,"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 / െ£യിമ¾Àെ¾ ഒ¬്/ഇടത് ൈകയിെല ബിംബം","options":[],"required":true,"pdf_field":""},{"help":"Enter date when Covid-19 was diagnosed","type":"date","label":"Date of diagnosis of Covid-19/ േകാവിഡ്-19 േരാഗനിർണയ തീയതി","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Witness Declaration","fields":[{"help":"Enter full name of witness","type":"text","label":"Name of witness / സാzിയുെട േപര്","options":[],"required":true,"pdf_field":""},{"help":"Enter witness address","type":"text","label":"Address of witness/ സാzിയുെട വിലാസം","options":[],"required":true,"pdf_field":""},{"help":"Witness must sign","type":"signature","label":"Signature of witness/ സാzിയുെട ഒ¬്","options":[],"required":true,"pdf_field":""},{"help":"Enter witness contact number","type":"phone","label":"Contact no. of witness/ സാzിയുെട േഫാൺ ന›ർ","options":[],"required":false,"pdf_field":""},{"help":"Select the category of witness","type":"choice","label":"Witness declaration to be signed by any of these / താെഴ¬റയു”വയിൽ ആെര}ിലും സാzÂെ¬ടുണം","options":["Person of local standing / ്രപാേദശിക വിശÇാസÂതയു¡ വÂ|ി","Special Executive Magistrate / സ്െപഷÂൽ എക്സികÂ˨ീവ് മജിസ്േ്രടµ്","Notary / േനാ¨റി","Lawyer / വ{ീൽ","Class 1 Gazette Officer / £ാസ് 1 ഗസµഡ് ഓഫിസർ"],"required":true,"pdf_field":""}],"filled_by":"witness"}],"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 claimant declares that all answers and statements are true and that submitting this form does not admit insurance in force or waive any rights.","The claimant consents to Bandhan Life Insurance Ltd. and its representatives obtaining all relevant records and conducting investigations as deemed fit.","The claimant agrees that payment of claim amount discharges Bandhan Life Insurance Ltd. of its liability.","If the claimant signs in vernacular or with thumb impression, a witness must sign a declaration confirming explanation and understanding."],"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/94-claim-form-covid-19-rider-19-o"}