{"id":95,"title":"Claim Form - Covid 19 Rider / कोҴवड-१९ रायडरसाठҦ दावा अजर्","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_Marathi.pdf","sha256":"fcbe2ed1a683a593d15e11c8ea44c080a1a451adfaff2a6b0159240499b2300b","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 should 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.","Attach self-attested cancelled cheque or bank passbook copy with pre-printed name of beneficiary for payout.","Use original or self-attested copies of required documents.","If claimant signs with thumb impression or in vernacular, witness signature is mandatory."],"title":"Claim Form - Covid 19 Rider / कोҴवड-१९ रायडरसाठҦ दावा अजर्","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of the Insured / बीҴमत Ќҵ͑ का Ҵववरण","fields":[{"help":"","type":"text","label":"City/ शहर","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State / रा󰈗य","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pincode / 󰇎पनकोड","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured name/ 󰇏वमा घेतले󰈂या 󰈄य󰊊󰇛चे नाव","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender/ 󰇒ल󰇝ग","options":["Male/ पु󰊁ष","Female/ म󰇎हला","Third Gender/तृतीय 󰇒ल󰇝ग"],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of birth/ ज󰇹म तारीख","options":[],"required":null,"pdf_field":""},{"help":"Full residential address","type":"text","label":"Complete address/ संपूण󰇟 प󰊋ा","options":[],"required":null,"pdf_field":""},{"help":"Insurance certificate number","type":"text","label":"Certificate of insurance no./ 󰇏वमा 󰈯माणप󰈪 󰈚मांक","options":[],"required":null,"pdf_field":""},{"help":"Enter 10-digit mobile number","type":"phone","label":"Mobile No/ मोबाईल 󰈚मांक","options":[],"required":null,"pdf_field":""},{"help":"Master policy number","type":"text","label":"Master policy no./ मा󰈈टर पॉ󰇒लसी 󰈚मांक","options":[],"required":null,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"Email/ ईमेल","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Bank Account Details / बँक खा󰈘याची मा󰇎हती","fields":[{"help":"Name of the bank for payout","type":"text","label":"Bank Name/ बँकेचे नाव","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of the bank branch","type":"text","label":"IFSC Code/ आयएफएससी कोड","options":[],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No/ खाते 󰈚मांक","options":[],"required":true,"pdf_field":""},{"help":"Select type of bank account","type":"choice","label":"Account Type/ खा󰈘याचा 󰈯कार","options":["Savings/ बचत","Current/ चालू"],"required":true,"pdf_field":""},{"help":"MICR code of the bank branch","type":"text","label":"MICR code/ एमआयसीआर कोड","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Hospitalization / 󰊁󰇧णालयात भरती संबंधी मा󰇎हती","fields":[{"help":"Name of the hospital where admitted","type":"text","label":"Name of hospital/ 󰊁󰇧णालयाचे नाव","options":[],"required":null,"pdf_field":""},{"help":"Full address of the hospital","type":"text","label":"Complete address of the hospital/ 󰊁󰇧णालयाचा संपूण󰇟 प󰊋ा","options":[],"required":null,"pdf_field":""},{"help":"Date of hospital admission","type":"date","label":"Date of admission/ भरती हो󰇴याची तारीख","options":[],"required":null,"pdf_field":""},{"help":"Time of admission","type":"text","label":"Time/ वेळ","options":[],"required":false,"pdf_field":""},{"help":"Date of hospital discharge","type":"date","label":"Date of discharge/ सु󰊎ीची तारीख","options":[],"required":null,"pdf_field":""},{"help":"Time of discharge","type":"text","label":"Time/ समय","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration & Authorization / घोषणा आҹण अҶधकृतता","fields":[{"help":"Sign or affix left thumb impression","type":"signature","label":"Signature/ Left thumb impression of claimant दावेदाराची 󰈈वा󰊈री / डा󰈄या अंग󰊓ाचा ठसा","options":[],"required":true,"pdf_field":""},{"help":"Date when Covid-19 was diagnosed","type":"date","label":"Date of diagnosis of Covid-19/ को󰇏वड-१९ 󰇎नदानाची तारीख","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Vernacular Declaration / ЫाҴनक भाषेतील घोषणापʕ","fields":[{"help":"Name of the witness who explained the form","type":"text","label":"Name of witness / सा󰊈ीदाराचे नाव","options":[],"required":true,"pdf_field":""},{"help":"Address of the witness","type":"text","label":"Address of witness/ सा󰊈ीदाराचा प󰊋ा","options":[],"required":true,"pdf_field":""},{"help":"Signature of the witness","type":"signature","label":"Signature of witness/  सा󰊈ीदाराची 󰈈वा󰊈री","options":[],"required":true,"pdf_field":""},{"help":"Contact number of the witness","type":"phone","label":"Contact no. of witness/ सा󰊈ीदाराचा संपक󰇟 󰈚मांक","options":[],"required":false,"pdf_field":""},{"help":"Select the category of the witness signing the declaration","type":"choice","label":"Witness declaration to be signed by any of these / सा󰊈ीदारां󰇪या घोषणेवर यापैक󰇛 कोण󰈘याही 󰈄य󰊊󰇛ने 󰈈वा󰊈री करावी","options":["Person of local standing / 󰈈था󰇎नक 󰈯󰇎त󰇏󰊧त 󰈄य󰊊󰇛","Notary / नोटरी","Class 1 Gazette Officer / वग󰇟 १ राजप󰇎󰈪त अ󰇐धकारी","Special Executive Magistrate / 󰇏वशेष काय󰇟कारी दंडा󰇐धकारी","Lawyer / वक󰇛ल"],"required":true,"pdf_field":""}],"filled_by":"witness"}],"deadlines":[],"applies_to":"Covid 19 Rider claims","attachments":["Claim form duly filled & signed / यो󰇧य 󰈯कारे भरलेला आ󰇑ण 󰈈वा󰊈री केलेला दावा फॉम󰇟","Copy of Hospital discharge summary / 󰊁󰇧णालयातून सु󰊎ी 󰇎द󰈂याचा अहवालची 󰈯त","Copy of Covid-19 test report & other lab reports / को󰇏वड-१९ चाचणी अहवाल व इतर 󰈯योगशाळा चाच󰇴यांचे अहवाल यांची 󰈯त","KYC documents of claimant / दावेदाराचे केवायसी कागदप󰈪े","PAN or Form No 60 / पॅन 󰇎क󰇝वा फॉम󰇟 󰈚मांक ६०","Copy of any one of the following (Identity & address proof of claimant) / खालीलपैक󰇛 कोण󰈘याही एकाची 󰈯त (दावेदाराचे ओळख व प󰊙याचा पुरावा)","Copy of self-attested cancelled cheque bearing pre-printed name of beneficiary/Passbook copy of the claimant / लाभा󰇶या󰇟चे नाव छापील असलेला 󰈈वह󰈈ता󰊈󰇍रत र󰊡 केलेला धनादेश / दावा करणा󰈀या󰇪या पासबुकची 󰈯त"],"declarations":["The claimant declares that all answers and statements are true and that submitting this form does not mean the company admits insurance was in force or waives any rights.","The claimant consents to Bandhan Life Insurance Ltd. obtaining all relevant records and conducting investigations as needed.","The claimant agrees that payment of the claim amount discharges Bandhan Life Insurance Ltd. of liability.","If the claimant signs in vernacular or with thumb impression, a witness must sign a declaration confirming the form was explained and understood."],"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/95-claim-form-covid-19-rider"}