{"id":1448,"title":"Cashless Request Form","purpose":"claim","insurer":{"slug":"universal-sompo-general-insurance","name":"Universal Sompo General Insurance Company Limited"},"source_pdf":"https://www.universalsompo.com/assets/file/claims/part-c-cashless-request-form.pdf","sha256":"25ce3c07b28c4e8927c5bdc1b820a5eef1e31b27239b135173fef95d005c3bd8","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used to request cashless hospitalisation under a health insurance policy. It is filled by the insured/patient, the hospital, and the treating doctor.","notes":["Use original bills only","Patient declaration must be signed in presence of hospital staff","Hospital documents must be sent within 7 days of discharge","All documents must be countersigned by insured/patient","Refer to policy terms and conditions for admissibility of expenses","Contact insurer toll free helpline 1800 200 4030 for clarifications","Use block letters where applicable"],"title":"Cashless Request Form","submit":{"to":"Universal Sompo General Insurance Company Ltd","how":"","address":"Health Claims Management: Universal Sompo General Insurance Co Ltd, 1st Floor, Plot No.- C 56 A/13, Sector - 62, Noida, Uttar Pradesh -201309"},"purpose":"claim","sections":[{"title":"To be filled by the Insured / Patient","fields":[{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"c) Age:","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"d) Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"f) Contact number of attending relative:","options":[],"required":null,"pdf_field":""},{"help":"As printed on your insurance card","type":"text","label":"g) Insured card ID number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"i) Employee ID:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"j) Currently do you have any other Mediclaim / Helath Insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"k) Do you have a family physician?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"l) Name of the family physician:","options":[],"required":null,"pdf_field":""},{"help":"Full current address","type":"text","label":"n) Current Address of Insured Patient:","options":[],"required":null,"pdf_field":""},{"help":"Full name as per policy","type":"text","label":"a) Name of the Patient:","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"b) Contact number:","options":[],"required":null,"pdf_field":""},{"help":"Brief description of illness or disease","type":"text","label":"c) Nature of illness/ disease","options":[],"required":true,"pdf_field":""},{"help":"Duration in days or months","type":"text","label":"e) Duration of the present ailment:","options":[],"required":null,"pdf_field":""},{"help":"Details of any other treatment taken","type":"text","label":"j) If other treatment, provide details:","options":[],"required":null,"pdf_field":""},{"help":"Explain cause of injury if applicable","type":"text","label":"k) How did the injury occur?","options":[],"required":null,"pdf_field":""},{"help":"If maternity case","type":"date","label":"i) Expected Date of Delivery:","options":[],"required":null,"pdf_field":""},{"help":"Contact number related to maternity","type":"phone","label":"m) Contact number, if any:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"o) Occupation of Insured Patient:","options":[],"required":null,"pdf_field":""},{"help":"Details of other treatments if any","type":"text","label":"j) If other treatment, provide details:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"v) Injury /Disease caused due to substance abuse /alcohol consumption:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach reports if yes","type":"yes-no","label":"vi) Test conducted to extablish this?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"To be filled by the Hospital","fields":[{"help":"","type":"text","label":"a) Name of the Hospital:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"b) Address:","options":[],"required":true,"pdf_field":""},{"help":"Hospital identification number","type":"text","label":"c) ROHINI ID:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"d) Email ID:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"e) Contact number:","options":[],"required":null,"pdf_field":""},{"help":"Policy number or corporate name as per insurance","type":"text","label":"h) Policy number / Name of corporate:","options":[],"required":true,"pdf_field":""},{"help":"Select one","type":"choice","label":"g) Proposed line of treatment:","options":["Medical Management","Surgical Management","Intensive Care"],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"To be filled by the Treating Doctor / Hospital","fields":[{"help":"","type":"text","label":"a) Name of the treating doctor:","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"b) Gender:","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"International Classification of Diseases code","type":"text","label":"i. ICD 10 Code:","options":[],"required":null,"pdf_field":""},{"help":"Procedure Coding System code","type":"text","label":"i. ICD 10 PCS Code:","options":[],"required":null,"pdf_field":""},{"help":"Preliminary diagnosis","type":"text","label":"f) Provisional diagnosis:","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"i. Date of first consultation:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"ii. Past history of present ailment, if any:","options":[],"required":null,"pdf_field":""},{"help":"Details of past history or other relevant info","type":"text","label":"ii. Give details:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"i. Route of drug administration:","options":[],"required":null,"pdf_field":""},{"help":"Details of investigations or medical management","type":"text","label":"h) If investigation & / or Medical Management, provide details:","options":[],"required":null,"pdf_field":""},{"help":"Name of surgery if applicable","type":"text","label":"i) If Surgical, name of surgery:","options":[],"required":null,"pdf_field":""},{"help":"If injury related","type":"date","label":"i) Date of injury:","options":[],"required":null,"pdf_field":""},{"help":"Road Traffic Accident","type":"yes-no","label":"i) Is it RTA?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Whether police report was filed","type":"yes-no","label":"iii. Report to Police:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Police FIR number if applicable","type":"text","label":"iv. FIR No.:","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Details of Patient Admitted","fields":[{"help":"","type":"date","label":"a) Date of admission:","options":[],"required":true,"pdf_field":""},{"help":"Time of admission","type":"text","label":"b) Time:","options":[],"required":null,"pdf_field":""},{"help":"Hospital registration number","type":"text","label":"c) Registration number with state code:","options":[],"required":null,"pdf_field":""},{"help":"Select one","type":"choice","label":"c) Is this an emergency / a planned hospitalization event?","options":["Emergency","Planned"],"required":true,"pdf_field":""},{"help":"Number of days expected","type":"number","label":"e) Expected no. of days/ Stay in hospital:","options":[],"required":null,"pdf_field":""},{"help":"Number of ICU days expected","type":"number","label":"f) Days in ICU:","options":[],"required":null,"pdf_field":""},{"help":"Type of room requested","type":"text","label":"g) Room Type","options":[],"required":null,"pdf_field":""},{"help":"Expected daily charges","type":"amount","label":"h) Per Day Room Rent + Nursing & Service Charges + Patient's Diet","options":[],"required":null,"pdf_field":""},{"help":"Expected cost for investigations","type":"amount","label":"i) Expected cost of investigation + diagnostic","options":[],"required":null,"pdf_field":""},{"help":"Expected ICU charges","type":"amount","label":"j) ICU Charges","options":[],"required":null,"pdf_field":""},{"help":"Expected operation theatre charges","type":"amount","label":"k) OT Charges","options":[],"required":null,"pdf_field":""},{"help":"Expected professional fees","type":"amount","label":"l) Professional fees Surgeon + Anesthetist Fees + consultation charges","options":[],"required":null,"pdf_field":""},{"help":"Expected cost of medicines and consumables","type":"amount","label":"m) Medicines + Consumables + Cost of implants (if applicable, please specify), other hospital expenses, if any","options":[],"required":null,"pdf_field":""},{"help":"Any other expected hospital expenses","type":"amount","label":"n) Other hospital expenses if any","options":[],"required":null,"pdf_field":""},{"help":"Package charges if applicable","type":"amount","label":"o) All inclusive package charges, if any applicable","options":[],"required":null,"pdf_field":""},{"help":"Total expected cost","type":"amount","label":"p) Sum Total expected cost of hospitalization","options":[],"required":true,"pdf_field":""},{"help":"List any chronic illnesses","type":"text","label":"d) Mandatory : Past history of any chronic illness","options":[],"required":true,"pdf_field":""},{"help":"Details of other ailments if any","type":"text","label":"Any other Ailment, give details:","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital / doctor"},{"title":"Declaration by the Patient / Representative","fields":[{"help":"Full name","type":"text","label":"a) Patient’s / Insured’s Name:","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"b) Contact number:","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"d) Patient’s / Insured’s Signature:","options":[],"required":true,"pdf_field":""},{"help":"Time of signing","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""}],"filled_by":"patient / representative"},{"title":"Declaration by the Treating Doctor","fields":[{"help":"","type":"text","label":"a) Name of the treating Doctor:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"b) Qualification:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"c) Email ID (optional):","options":[],"required":false,"pdf_field":""},{"help":"Date of declaration","type":"date","label":"e) Date:","options":[],"required":true,"pdf_field":""},{"help":"Official hospital seal","type":"signature","label":"Hospital Seal (must include hospital ID)","options":[],"required":true,"pdf_field":""},{"help":"Signature of patient or insured","type":"signature","label":"Patient / Insured Name & Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"}],"deadlines":["All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to Universal Sompo General Insurance Company Ltd within 7 days of the patient's discharge"],"applies_to":"Health insurance cashless hospitalisation requests","attachments":["If yes attach reports (for tests conducted to establish substance abuse/alcohol consumption)","Detailed Discharge Summary and all Bills from the hospital","Cash Memos from the Hospitals / Chemists supported by proper prescription","Receipts and Pathological Test Reports from Pathologists, supported by note from the attending Medical Practitioner / Surgeon recommending such pathological Tests","Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt","The patient declaration has been signed by the patient or by his representative in our presence"],"declarations":["I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Universal Sompo General Insurance Company Ltd after the discharge and to sign on the Final Bill & the Discharge Summary before discharge","Payment to hospital is governed by the terms and conditions of the policy; if insurer is not liable, I undertake to settle the bill as per policy terms","All non-medical expenses and expenses not relevant to current hospitalization or amounts over policy limits will be paid by me","If any false or untrue statement is made, my claim reimbursement rights shall be forfeited","I agree to indemnify the hospital against expenses not reimbursed by the insurer","I authorize Universal Sompo General Insurance Company Ltd to contact me through mobile/email for claim updates","I agree to abide by the terms and conditions of the policy and indemnify the insurer if facts disclosed are false or incorrect","Insurer does not warrant hospital services or guarantee quality or standard of services","Hospital confirms no additional amount will be collected from insured beyond agreed package rates except for non-admissible amounts","Hospital agrees to provide clarifications for queries and takes responsibility for any delay","Hospital agrees no recoveries will be made from deposit except for non-admissible amounts","In case of unauthorized recovery of additional amount, insurer reserves right to recover from hospital or take action"],"dropped_labels":2},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"contactclaims@universalsompo.com","label":"Claims Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/resourse-grievance-redressal/","quote":"e Claim Details\nTPA’s Servicing Group Health Insurance\nDownload Pulz App\nConnect with Us\ncontactus@universalsompo.com\ncontactclaims@universalsompo.com\nHealth Insurance :\nComplete Healthcare Insurance\nA Plus Health Insurance\nSaral Suraksha Bima\nGroup Mashak Rakshak Polic","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"contactus@universalsompo.com","label":"Theft Claim Email","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.universalsompo.com/claimintimation/","quote":"ntimate claim.\nFor\nTheft Claim\n, please connect with us on below details.\nPhone:\n1800-22-4030\n,\n1800-200-4030\nor\nEmail:\ncontactus@universalsompo.com\nOk\nView All Policies\nHealth Insurance\nComplete Healthcare Insurance\nSuper Healthcare Insurance\nArogya SanjeevaniInsuran","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-22-4030","label":"Claims Toll Free Number (MTNL/BSNL Lines)","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/claims/","quote":null,"fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022-41582900 - 41582999","label":"Claims Helpline Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/claims/","quote":"tactclaims@universalsompo.com 2. Call on our Toll Free number 1-800-22-4030 (from MTNL & BSNL Lines) 3. Helpline number 022-41582900 - 41582999\nIn case of telephonic contact, our call centre executive shall note down the basic requirements and pass on the informa","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-200-4030","label":"Motor Claim Intimation Toll Free","level":null,"hours":"24/7","applies_to":"motor","source_url":"https://www.universalsompo.com/claimintimation/","quote":"Motor Claim Intimation for Coverage | Universal Sompo\n24/7, Customer Care\n1800-22-4030\n,\n1800-200-4030\nCrop Helpline No.\n1800-200-5142\nSenior Citizen\n1800-267-4030\nAbout\r\n                                us\nContact Us\nLogin","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-200-5142","label":"Crop Helpline Number","level":null,"hours":null,"applies_to":"crop","source_url":"https://www.universalsompo.com/claimintimation/","quote":"otor Claim Intimation for Coverage | Universal Sompo\n24/7, Customer Care\n1800-22-4030\n,\n1800-200-4030\nCrop Helpline No.\n1800-200-5142\nSenior Citizen\n1800-267-4030\nAbout\r\n                                us\nContact Us\nLogin\nI am a Customer\nI am an Agent\nP","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/universal-sompo-general-insurance/1448-cashless-request-form"}