{"id":1455,"title":"Zuno Health Top Up Insurance Claim form","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Health_top_up_insurance_claim_form_A_V_1_0_49b7caccb3.pdf?updated_at=2024-09-26T06:01:24.867Z","sha256":"ee121c1c0c25a001e60d9c579499ccbb28b52d5877e2645d88f71a754038e1d6","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or policyholder to claim health insurance benefits under the Zuno Health Top Up Insurance policy.","notes":["Fill the form in BLOCK letters.","Submission of this form does not guarantee claim acceptance.","Use dd-mm-yy format for dates and hh:mm format for times.","Do not enter paise values in amount fields.","Attach original bills and relevant documents as listed.","Tick the correct options where applicable.","Provide full postal addresses including city, state, and pin code.","Include STD code with telephone numbers."],"title":"Zuno Health Top Up Insurance Claim form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section A – Details of primary insured","fields":[{"help":"Enter the policy number as given by the insurance company","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter the social insurance number or certificate number of social health insurance scheme","type":"text","label":"Serial No./ certificate No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA id number as given in TPA documents","type":"text","label":"Company/ TPA ID No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter the Aadhaar number as given by UIDAI","type":"text","label":"Aadhaar:","options":[],"required":null,"pdf_field":""},{"help":"Include street, city and pin code","type":"text","label":"Address- City:","options":[],"required":null,"pdf_field":""},{"help":"State of residence","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Nearby landmark for address","type":"text","label":"Landmark:","options":[],"required":false,"pdf_field":""},{"help":"Postal pin code","type":"number","label":"Pin code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Phone No.:","options":[],"required":false,"pdf_field":""},{"help":"Complete email address","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section B – Some details of your other/past insurance","fields":[{"help":"Tick yes or no","type":"choice","label":"Are you currently covered by any other mediclaim/ health insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the full name of the insurance company","type":"text","label":"If yes, company name:","options":[],"required":false,"pdf_field":""},{"help":"Enter the policy number","type":"text","label":"Policy number:","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured in rupees","type":"amount","label":"Sum insured (INR):","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"choice","label":"Have you been hospitalized in the last four years since the beginning of the policy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date:","options":[],"required":false,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis:","options":[],"required":false,"pdf_field":""},{"help":"Enter details of other insurance policy","type":"text","label":"If yes, please specify the details.","options":[],"required":false,"pdf_field":""},{"help":"Enter the insurance company name","type":"text","label":"Name of the insurance company:","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number","type":"text","label":"Policy No:","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured in rupees","type":"amount","label":"Sum insured:","options":[],"required":false,"pdf_field":""},{"help":"Enter claimed amount in rupees","type":"amount","label":"Claimed amount:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section C – Details of insured person hospitalized","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter Aadhaar or government issued ID or PAN number","type":"text","label":"Aadhaar / identity document and No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN card number","type":"text","label":"Pan card No:","options":[],"required":false,"pdf_field":""},{"help":"Tick the correct gender option","type":"choice","label":"Gender:","options":["Male","Female","Third gender"],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of birth:","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct relationship or specify if Other","type":"choice","label":"Relationship with primarily insured:","options":["Self","Spouse","Child","Father","Mother","Other (please specify)"],"required":null,"pdf_field":""},{"help":"Tick the correct occupation or specify if Other","type":"choice","label":"Occupation:","options":["Service","Self-employed","Homemaker","Student","Retired","Other (please specify)"],"required":null,"pdf_field":""},{"help":"Enter full postal address if different","type":"text","label":"Address (if different from above): city:","options":[],"required":false,"pdf_field":""},{"help":"State of residence","type":"text","label":"State:","options":[],"required":false,"pdf_field":""},{"help":"Postal pin code","type":"number","label":"Pin code:","options":[],"required":false,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Phone No.:","options":[],"required":false,"pdf_field":""},{"help":"Complete email address","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section D – Tell us more about the hospitalization","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of hospital admitted:","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital address","type":"text","label":"Address:","options":[],"required":false,"pdf_field":""},{"help":"Nearby landmark for hospital","type":"text","label":"Landmark:","options":[],"required":false,"pdf_field":""},{"help":"Tick the correct room category","type":"choice","label":"Room category occupied:","options":["Day care","Single occupancy","Twin sharing","3 or more beds per room"],"required":null,"pdf_field":""},{"help":"Tick the reason for hospitalization","type":"choice","label":"Hospitalization due to:","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of admission:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of discharge:","options":[],"required":null,"pdf_field":""},{"help":"Tick the cause if injury","type":"choice","label":"If injury, give cause:","options":["Self inflicted","Road traffic accident","Substance abuse/alcohol consumption"],"required":false,"pdf_field":""},{"help":"Tick yes or no for each question","type":"checkbox","label":"If medico legal: (i)Yes No (ii) Reported to police: Yes No (iii) MLC report & police FIR attached: Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter system of medicine followed","type":"text","label":"System of medicine:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section E – Details of claim","fields":[{"help":"Columns: (i) Pre-hospitalization cost, (ii) Hospitalization cost, (iii) Post-hospitalization cost, (iv) Daycare, (v) Hospital cash being claimed, (vi) Details of Base Policy Co-Pay Support claimed, (vii) Pre-hospitalization period (days), (viii) Details of Base Policy Higher room rent deduction, (ix) Post-hospitalization period (days), (x) Others expenses claimed as per policy cover (code)","type":"table","label":"Details of the treatment being claimed for","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no; if yes, provide details in annexure","type":"choice","label":"Claim for Domiciliary Hospitalization:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amount claimed for dental cover","type":"amount","label":"Details of Dental Cover Claimed:","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed for AYUSH hospitalization or daycare","type":"amount","label":"Details of AYUSH Hospitalization or AYUSH Day care:","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed for newborn baby cover","type":"amount","label":"Details of expenses under New Born baby cover:","options":[],"required":false,"pdf_field":""},{"help":"Enter vaccination expenses if opted for newborn cover","type":"amount","label":"Vaccination if opted for new born cover:","options":[],"required":false,"pdf_field":""},{"help":"List any additional supporting documents attached","type":"text","label":"Any additional / supporting documents:","options":[],"required":false,"pdf_field":""},{"help":"Enter total claimed amount in rupees","type":"amount","label":"Total:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section F – Details of bills enclosed","fields":[{"help":"List bills with number, date, issuer, purpose and amount","type":"table","label":"Sl.No., Bill No., Date, Issued by, Towards, Amount (`)","options":[],"required":null,"pdf_field":""},{"help":"Number of hospital main bills enclosed","type":"number","label":"Hospital main bill","options":[],"required":null,"pdf_field":""},{"help":"Number of pre-hospitalization bills enclosed","type":"number","label":"Pre-hospitalization bills: ___ Nos","options":[],"required":null,"pdf_field":""},{"help":"Number of post-hospitalization bills enclosed","type":"number","label":"Post-hospitalization Bills: ___Nos","options":[],"required":null,"pdf_field":""},{"help":"Number of pharmacy bills enclosed","type":"number","label":"Pharmacy bills","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section G - details of primarily insured’s bank account","fields":[{"help":"Enter PAN as given by income tax department","type":"text","label":"PAN:","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter full bank name and branch","type":"text","label":"Bank name and branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary for cheque/DD","type":"text","label":"Cheque/DD payable details:","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section H – declaration by the insured","fields":[{"help":"Enter date in dd-mm-yy format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / policyholder"}],"deadlines":[],"applies_to":"Zuno Health Top Up Insurance claims","attachments":["Duly signed Claim Form","ECG","Copy of the claim intimation, if any","Doctor's request for investigation","Hospital Main bill","Investigation Reports (Including CT/MRI / USG / HPE)","Hospital Break-up bill","Doctor’s Prescriptions","Hospital release in short","Hospital Bill Payment Receipt","Pharmacy Bill","Operation Theatre Notes"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","If any false or untrue statement, suppression or concealment of material fact is made, the right to claim reimbursement shall be forfeited.","I consent and authorize TPA / insurance company to seek necessary medical information from any hospital or medical practitioner.","I declare that all bills and receipts for this claim are included and no supplementary claim except pre/post hospitalization claim will be made.","I authorize Zuno General Insurance / Zuno authorized TPA to collect relevant medical documents for my claim from the treatment provider."],"dropped_labels":5},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"support@hizuno.com","label":"Health claims support email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.hizuno.com/health-insurance/health-claim","quote":"ls, you will need to submit a reimbursement claim. For cashless services at a common network hospital, you can write to\nsupport@hizuno.com\n, call us at 1800 12000, or connect with your TPA as mentioned on your card.\nWhen you’re covered by a health insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 12000","label":"Health claims toll free number","level":null,"hours":null,"applies_to":"health","source_url":"https://www.hizuno.com/health-insurance/health-claim","quote":"imbursement claim. For cashless services at a common network hospital, you can write to\nsupport@hizuno.com\n, call us at 1800 12000, or connect with your TPA as mentioned on your card.\nWhen you’re covered by a health insurance policy and need to be ho","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 423 12000","label":"Paid Landline","level":null,"hours":null,"applies_to":"all","source_url":"https://www.hizuno.com/contact-us","quote":"uote\nHome\nContact us\nReach out to us for any Query/ Request or Grievance\nCall us\nToll free - 1800 12000\nPaid Landline -\n022 423 12000\nSenior citizen -\n022 423 12001\nEmail address\nsupport@hizuno.com\nsenior.citizen@hizuno.com\nGrievance Redressal Officer\nM","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/zuno-general-insurance/1455-zuno-health-top-up-insurance-claim-form"}