{"id":99,"title":"TERMINAL ILLNESS BENEFIT CLAIM FORM","purpose":"claim","insurer":{"slug":"bandhan-life-insurance","name":"Bandhan Life Insurance Limited"},"source_pdf":"https://www.bandhanlife.com/sites/default/files/asset/2026-04/Doctor%27s%20Certificate%20-%20Terminal%20Illness.pdf","sha256":"c065bc63317eccb857eaff6103ca5bb0299ff53a4ad7213e9407e8900e145222","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for an insured person to claim the Terminal Illness Benefit and must be completed by the insured’s treating Specialist Doctor.","notes":["If any section cannot be completed, provide written reasons.","If there is insufficient space, use additional pages and clearly indicate the related question.","Payment for completing this form is the responsibility of the insured.","Submission of this form without the required investigation reports will be treated as incomplete."],"title":"TERMINAL ILLNESS BENEFIT CLAIM FORM","submit":{"to":"Bandhan Life Insurance Limited","how":"","address":""},"purpose":"claim","sections":[{"title":"Patient Details and Diagnosis","fields":[{"help":"","type":"text","label":"Patient’s Full Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Patient’s Address","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Primary diagnosis of the patient","type":"text","label":"Diagnosis Primary","options":[],"required":null,"pdf_field":""},{"help":"Secondary diagnosis if any","type":"text","label":"Secondary","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date of Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"In your opinion, are you satisfied that the above-mentioned patient suffers from a terminal illness, or has incurred an injury, that is likely to result in their death within 6 months of the date of this report?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Additional comments or explanations","type":"text","label":"Comments","options":[],"required":null,"pdf_field":""}],"filled_by":"Specialist treating doctor"},{"title":"Declaration and Doctor’s Details","fields":[{"help":"Doctor’s signature","type":"signature","label":"Signature","options":[],"required":null,"pdf_field":""},{"help":"Format: DD/MM/YYYY","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Doctor’s official stamp or seal","type":"text","label":"Stamp/ Seal","options":[],"required":null,"pdf_field":""},{"help":"Doctor’s full name","type":"text","label":"Your Name","options":[],"required":null,"pdf_field":""},{"help":"Doctor’s medical qualifications","type":"text","label":"Qualifications","options":[],"required":null,"pdf_field":""},{"help":"Doctor’s clinic or hospital address","type":"text","label":"Surgery Address","options":[],"required":null,"pdf_field":""},{"help":"Contact phone number","type":"phone","label":"Phone","options":[],"required":null,"pdf_field":""},{"help":"Contact email address","type":"email","label":"Email","options":[],"required":null,"pdf_field":""}],"filled_by":"Specialist treating doctor"}],"deadlines":[],"applies_to":"Terminal Illness Benefit claims under Bandhan Life Insurance policies","attachments":["All investigation reports (e.g., Blood Reports, ECG, Angiography, Histopathology, Radiology Reports like CT scan, MRI etc.)","Discharge summary from the Hospital","Any other related report(s) based on which the diagnosis and prognosis has been derived"],"declarations":["The doctor declares that the details provided are true and correct."],"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/99-terminal-illness-benefit-claim-form"}