{"id":96,"title":"Claim Form - Covid 19 Rider / दावा ʛपʕ - कोҴवड 19 राइडर","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_Hindi.pdf","sha256":"0fb790471e9a7fc86e03dc0d08003caf9723ecb6eab530dc46587e885ee25c52","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.","Attach a self-attested cancelled cheque or bank passbook copy with pre-printed name of beneficiary for payout.","Use original or self-attested copies of documents as listed in the checklist.","If claimant signs with thumb impression or in vernacular, witness signature and details are mandatory."],"title":"Claim Form - Covid 19 Rider / दावा ʛपʕ - कोҴवड 19 राइडर","submit":{"to":"Bandhan Life Insurance Ltd.","how":"","address":"Registered office - A - 201, 2nd Floor, Leela Business Park, Andheri-Kurla Road, Andheri (E), Mumbai - 400059"},"purpose":"claim","sections":[{"title":"Details of the Insured","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/ बी󰇏मत का नाम","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":"Use date format as per form instructions","type":"date","label":"Date of birth/ ज󰇹म 󰇎त󰇏थ","options":[],"required":null,"pdf_field":""},{"help":"Fill in full postal address","type":"text","label":"Complete address/ पूण󰇟 पता","options":[],"required":null,"pdf_field":""},{"help":"Policy certificate number","type":"text","label":"Certificate of insurance no./ बीमा 󰈯माणप󰈪 नंबर","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile number with country code if applicable","type":"phone","label":"Mobile No/ मोबाइल नंबर","options":[],"required":null,"pdf_field":""},{"help":"Master policy number if applicable","type":"text","label":"Master policy no./ मा󰈈टर पॉ󰇒लसी नंबर","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","fields":[{"help":"Mandatory for payout processing","type":"text","label":"Bank Name/ बै󰇝क का नाम","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code/ आईएफएससी कोड","options":[],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No/ खाता नंबर","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Account Type/ खाते का 󰈯कार","options":["Savings/ बचत","Current/ चालू"],"required":true,"pdf_field":""},{"help":"MICR code of the bank branch","type":"text","label":"MICR code/ एमआईसीआर कोड","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Details of Hospitalization","fields":[{"help":"","type":"text","label":"Name of hospital/ अ󰈈पताल का नाम","options":[],"required":null,"pdf_field":""},{"help":"Full address of hospital where admitted","type":"text","label":"Complete address of the hospital/ अ󰈈पताल का पूण󰇟 पता","options":[],"required":null,"pdf_field":""},{"help":"Date of hospital admission","type":"date","label":"Date of admission/ भती󰇟 क󰇛 󰇎त󰇏थ","options":[],"required":null,"pdf_field":""},{"help":"Time of admission","type":"text","label":"Time/ समय","options":[],"required":false,"pdf_field":""},{"help":"Date of hospital discharge","type":"date","label":"Date of discharge/ छु󰊎ी क󰇛 󰇎त󰇏थ","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","fields":[{"help":"Sign or affix left thumb impression","type":"signature","label":"Signature/ Left thumb impression of claimant दावाकता󰇟 के ह󰈈ता󰊈र/बाएँ अंगूठे का 󰇎नशान","options":[],"required":true,"pdf_field":""},{"help":"Name of witness if claimant signs in vernacular or thumb impression","type":"text","label":"Name of witness / गवाह का नाम","options":[],"required":null,"pdf_field":""},{"help":"Address of witness","type":"text","label":"Address of witness/ गवाह का पता","options":[],"required":null,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of witness/ गवाह के ह󰈈ता󰊈र","options":[],"required":null,"pdf_field":""},{"help":"Phone number of witness","type":"phone","label":"Contact no. of witness/ गवाह का संपक󰇟 नंबर","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 / गवाह घोषणा को इनमे󰇝 से 󰇎कसी एक 󰊞ारा ह󰈈ता󰊈󰇍रत 󰇎कया जाना चा󰇎हए","options":["Person of local standing / 󰈈थानीय 󰈯󰇎त󰇏󰊧त 󰈄य󰇏󰊊","Notary / नोटरी","Class 1 Gazette Officer / 󰈺ेणी 1 राजप󰇎󰈪त अ󰇐धकारी","Special Executive Magistrate / 󰇏वशेष काय󰇟कारी म󰇐ज󰈈󰈥ेट","Lawyer / वक󰇛ल"],"required":null,"pdf_field":""},{"help":"Date when Covid-19 was diagnosed","type":"date","label":"Date of diagnosis of Covid-19/ को󰇏वड-19 के 󰇎नदान क󰇛 󰇎त󰇏थ","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Covid-19 Rider claims under Bandhan Life insurance policies","attachments":["Claim form duly filled & signed / दावा 󰈯प󰈪 पूण󰇟 󰊂प से भरा और ह󰈈ता󰊈󰇍रत","Copy of Hospital discharge summary / अ󰈈पताल से छु󰊎ी सारांश क󰇛 󰈯󰇎त","Copy of Covid-19 test report & other lab reports / को󰇏वड-19 परी󰊈ण 󰇍रपोट󰇟 और अ󰇹य 󰈯योगशाला 󰇍रपोट󰇟 क󰇛 󰈯󰇎त","KYC documents of claimant / दावाकता󰇟 के केवाईसी द󰈈तावेज़","PAN or Form No 60 / पैन या फॉम󰇟 सं󰇦या 60","Copy of any one of the following (Identity & address proof of claimant) / 󰇎न󰇾न󰇒ल󰇒खत मे󰇝 से 󰇎कसी एक क󰇛 󰈯󰇎त (दावाकता󰇟 क󰇛 पहचान और पते का 󰈯माण)","Copy of self-attested cancelled cheque bearing pre-printed name of beneficiary/Passbook copy of the claimant / लाभाथी󰇟 के पूव󰇟-मु󰇎󰈬त नाम वाला 󰈈वयं-अ󰇏भ󰈯मा󰇑णत र󰊡 󰇎कया गया चेक / दावाकता󰇟 क󰇛 पासबुक क󰇛 󰈯󰇎त"],"declarations":["The claimant declares that all answers and statements are true and that submitting this form does not admit any insurance in force or waive any 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.'s liability.","If claimant signs in vernacular or thumb impression, a witness must certify that the form contents were 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/96-claim-form-covid-19-rider-19"}