{"id":1093,"title":"Health Insurance Claim Form","purpose":"claim","insurer":{"slug":"royal-sundaram-general-insurance","name":"Royal Sundaram General Insurance Company Limited"},"source_pdf":"https://www.royalsundaram.in/assets/claim-forms/health-insurance/health-claim-form.pdf","sha256":"8ddb724f118555a920ef3290bc11cb8b45c547694c4bbe196280b4081e3eb58d","pages":10,"collected":"2026-10-20","instructions":{"about":"This form is used by policyholders or claimants to submit a health insurance claim for reimbursement or cashless treatment under their health insurance policy.","notes":["Fill the form in English and in BLOCK letters.","Fill the date in DD-MM-YYYY format.","Attach certified copies of identity and address proofs as listed.","Use the two-digit state/UT codes as per Indian Motor Vehicle Act, 1988.","Use the two-character ISO 3166 country codes for country selection.","Mobile number should be entered with country code and without leading zero.","For minors above 10 years, guardian details are optional for bank account opening.","Original bills and documents may be required for claim processing (not detailed in this form)."],"title":"Health Insurance Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Personal Details","fields":[{"help":"Enter your full name as per your ID proof","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter your date of birth in DD-MM-YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["M- Male","F- Female","T- Transgender"],"required":true,"pdf_field":""},{"help":"Permanent Account Number if available","type":"text","label":"PAN","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder / claimant"},{"title":"Proof of Identity and Address","fields":[{"help":"Enter your address as per proof of identity","type":"text","label":"Address Line 1","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City / Town / Village","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Pin (Post Code)","options":[],"required":true,"pdf_field":""},{"help":"Select the two-digit state or union territory code as per Indian Motor Vehicle Act, 1988","type":"choice","label":"State/U.T Code","options":["AN","AP","AR","AS","BR","CH","CG","DN","DD","DL","GA","GJ","HR","HP","JK","JH","KA","KL","LD","MP","MH","MN","ML","MZ","NL","OR","PY","PB","RJ","SK","TN","TS","TR","UP","UA","WB","xx"],"required":true,"pdf_field":""},{"help":"Select the two-character ISO 3166 country code","type":"choice","label":"ISO 3166 Country Code","options":["AF","AX","AL","DZ","AS","AD","AO","AI","AQ","AG","AR","AM","AW","AU","AT","AZ","BS","BH","BD","BB","BY","BE","BZ","BJ","BM","BT","BO","BQ","BA","BW","BV","BR","IO","BN","BG","BF","BI","CV","KH","CM","CA","KY","CF","TD","CL","CN","CX","CC","CO","KM","CG","CD","CK","CR","CI","HR","CU","CW","CY","CZ","DK","DJ","DM","DO","EC","EG","SV","GQ","ER","EE","SZ","ET","FK","FO","FJ","FI","FR","GF","PF","TF","GA","GM","GE","DE","GH","GI","GR","GL","GD","GP","GU","GT","GG","GN","GW","GY","HT","HM","VA","HN","HK","HU","IS","IN","ID","IR","IQ","IE","IM","IL","IT","JM","JP","JE","JO","KZ","KE","KI","KP","KR","KW","KG","LA","LV","LB","LS","LR","LY","LI","LT","LU","MO","MG","MW","MY","MV","ML","MT","MH","MQ","MR","MU","YT","MX","FM","MD","MC","MN","ME","MS","MA","MZ","MM","NA","NR","NP","NL","NC","NZ","NI","NE","NG","NU","NF","MK","MP","NO","OM","PK","PW","PS","PA","PG","PY","PE","PH","PN","PL","PT","PR","QA","RE","RO","RU","RW","BL","SH","KN","LC","MF","PM","VC","WS","SM","ST","SA","SN","RS","SC","SL","SG","SX","SK","SI","SB","SO","ZA","GS","SS","ES","LK","SD","SR","SJ","SE","CH","SY","TW","TJ","TZ","TH","TL","TG","TK","TO","TT","TN","TR","TM","TC","TV","UG","UA","AE","GB","US","UM","UY","UZ","VU","VE","VN","VG","VI","WF","EH","YE","ZM","ZW"],"required":true,"pdf_field":""}],"filled_by":"policyholder / claimant"},{"title":"Current Address Details","fields":[{"help":"Tick if current address is same as above; if ticked, no need to fill below address fields","type":"checkbox","label":"Same as above mentioned address","options":[],"required":false,"pdf_field":""},{"help":"Attach certified copy of one of the listed documents","type":"choice","label":"Proof of Address Document","options":["Passport Number","Voter ID Card","Driving Licence","NREGA Job Card","National Population Register Letter","Proof of Possession of Aadhaar","E-KYC Authentication","Offline verification of Aadhaar"],"required":true,"pdf_field":""},{"help":"Enter your current address","type":"text","label":"Address Line 1","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City / Town / Village","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"District","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Pin / Post Code","options":[],"required":true,"pdf_field":""},{"help":"Select the two-digit state or union territory code as per Indian Motor Vehicle Act, 1988","type":"choice","label":"State/U.T Code","options":["AN","AP","AR","AS","BR","CH","CG","DN","DD","DL","GA","GJ","HR","HP","JK","JH","KA","KL","LD","MP","MH","MN","ML","MZ","NL","OR","PY","PB","RJ","SK","TN","TS","TR","UP","UA","WB","xx"],"required":true,"pdf_field":""},{"help":"Select the two-character ISO 3166 country code","type":"choice","label":"ISO 3166 Country Code","options":["AF","AX","AL","DZ","AS","AD","AO","AI","AQ","AG","AR","AM","AW","AU","AT","AZ","BS","BH","BD","BB","BY","BE","BZ","BJ","BM","BT","BO","BQ","BA","BW","BV","BR","IO","BN","BG","BF","BI","CV","KH","CM","CA","KY","CF","TD","CL","CN","CX","CC","CO","KM","CG","CD","CK","CR","CI","HR","CU","CW","CY","CZ","DK","DJ","DM","DO","EC","EG","SV","GQ","ER","EE","SZ","ET","FK","FO","FJ","FI","FR","GF","PF","TF","GA","GM","GE","DE","GH","GI","GR","GL","GD","GP","GU","GT","GG","GN","GW","GY","HT","HM","VA","HN","HK","HU","IS","IN","ID","IR","IQ","IE","IM","IL","IT","JM","JP","JE","JO","KZ","KE","KI","KP","KR","KW","KG","LA","LV","LB","LS","LR","LY","LI","LT","LU","MO","MG","MW","MY","MV","ML","MT","MH","MQ","MR","MU","YT","MX","FM","MD","MC","MN","ME","MS","MA","MZ","MM","NA","NR","NP","NL","NC","NZ","NI","NE","NG","NU","NF","MK","MP","NO","OM","PK","PW","PS","PA","PG","PY","PE","PH","PN","PL","PT","PR","QA","RE","RO","RU","RW","BL","SH","KN","LC","MF","PM","VC","WS","SM","ST","SA","SN","RS","SC","SL","SG","SX","SK","SI","SB","SO","ZA","GS","SS","ES","LK","SD","SR","SJ","SE","CH","SY","TW","TJ","TZ","TH","TL","TG","TK","TO","TT","TN","TR","TM","TC","TV","UG","UA","AE","GB","US","UM","UY","UZ","VU","VE","VN","VG","VI","WF","EH","YE","ZM","ZW"],"required":true,"pdf_field":""}],"filled_by":"policyholder / claimant"},{"title":"Contact Details","fields":[{"help":"Office telephone number with country code","type":"phone","label":"Tel. (Off)","options":[],"required":false,"pdf_field":""},{"help":"Residence telephone number with country code","type":"phone","label":"Tel. (Res)","options":[],"required":false,"pdf_field":""},{"help":"Enter 2-digit country code followed by 10-digit mobile number without leading zero","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":""},{"help":"Enter your email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder / claimant"},{"title":"Remarks","fields":[{"help":"Any additional information","type":"text","label":"Remarks (If any)","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder / claimant"},{"title":"Applicant Declaration","fields":[{"help":"Date of signing the declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing the declaration","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign or put thumb impression here","type":"signature","label":"Signature / Thumb Impression of Applicant","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder / claimant"}],"deadlines":[],"applies_to":"health insurance claims","attachments":["Certified copy of Proof of Identity Document","Certified copy of Proof of Address Document"],"declarations":["I declare that the details furnished are true and correct to the best of my knowledge and belief.","I undertake to inform you of any changes immediately.","I am aware that if any information is false or misleading, I may be held liable.","I consent to receiving information from Central KYC Registry through SMS/Email on the registered number/email address."],"dropped_labels":5},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/royal-sundaram-general-insurance/1093-health-insurance-claim-form"}