{"id":1459,"title":"Zuno Group Total Protect Policy Claim Form","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Group_Total_Protect_Policy_Claim_Form_V_1_1_1f9d716cc0.pdf?updated_at=2024-09-26T06:01:23.169Z","sha256":"37254625a152825dfae82324206faf50983e79de4f0636f1fa054523b08cd302","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or claimant to file a claim under the Zuno Group Total Protect Policy.","notes":["Fill all details in BLOCK LETTERS.","All fields in this form are mandatory.","If additional information is needed, write on a separate sheet, sign it and attach to this form.","Use original documents as required.","This form should be filled by the insured person/claimant.","Issuance of this form does not imply acceptance of liability."],"title":"Zuno Group Total Protect Policy Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Instructions and Basic Details","fields":[{"help":"","type":"text","label":"Master policy No.:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Company/TPA/ASP/Policyholder issued ID card no.:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of insured Person:","options":[],"required":true,"pdf_field":""},{"help":"Specify the type of photo identity proof","type":"text","label":"Photo identity proof:","options":[],"required":true,"pdf_field":""},{"help":"Fill only if applicable","type":"text","label":"Passport No: (wherever applicable)","options":[],"required":true,"pdf_field":""},{"help":"Include city, state, country, landmark, postal code","type":"text","label":"Address as per photo identity proof:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Country:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Landmark:","options":[],"required":true,"pdf_field":""},{"help":"Postal or ZIP code","type":"text","label":"Postal code:","options":[],"required":true,"pdf_field":""},{"help":"Date format DD MM YYYY","type":"date","label":"Date of joining/associating:","options":[],"required":true,"pdf_field":""},{"help":"Include country and area code if applicable","type":"phone","label":"Phone No:","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email:","options":[],"required":true,"pdf_field":""},{"help":"Fill if employed","type":"text","label":"Name of company (if applicable):","options":[],"required":true,"pdf_field":""},{"help":"Employee number if applicable","type":"text","label":"Employee No:","options":[],"required":true,"pdf_field":""},{"help":"Branch of the company","type":"text","label":"Branch location:","options":[],"required":true,"pdf_field":""},{"help":"Fill only if answered Yes above","type":"text","label":"If yes, please specify the details.","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurance company if applicable","type":"text","label":"Name of the insurance company:","options":[],"required":false,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"Policy No.:","options":[],"required":false,"pdf_field":""},{"help":"Sum insured under other policy","type":"amount","label":"Sum insured:","options":[],"required":false,"pdf_field":""},{"help":"Amount claimed under other policy","type":"amount","label":"Claimed amount:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"Section A – Details of insured person","fields":[{"help":"Date format DD MM YYYY","type":"date","label":"Date of joining/associating:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"Section B – Details of insured person/claimant claiming for coverage under the policy","fields":[{"help":"","type":"text","label":"Name of the insured person/ claimant:","options":[],"required":true,"pdf_field":""},{"help":"Number on photo identity card","type":"text","label":"Photo identity card No:","options":[],"required":true,"pdf_field":""},{"help":"Select one","type":"choice","label":"Gender: Male Female Third Gender","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Fill age in years and months","type":"number","label":"Age: Years Months","options":[],"required":true,"pdf_field":""},{"help":"Date format DD MM YYYY","type":"date","label":"Date of birth:","options":[],"required":true,"pdf_field":""},{"help":"Select one; specify if Other","type":"choice","label":"Relationship with Primarily Insured: Self Spouse Child Father Mother Other (Please Specify)","options":["Self","Spouse","Child","Father","Mother","Other"],"required":true,"pdf_field":""},{"help":"Select one; specify if Other","type":"choice","label":"Occupation: Service Self-employed Homemaker Student Retired Other (Please Specify)","options":["Service","Self-employed","Homemaker","Student","Retired","Other"],"required":true,"pdf_field":""},{"help":"Include city, state, country, landmark, postal code","type":"text","label":"Current Residential Address (if different from above)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Country:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Landmark:","options":[],"required":true,"pdf_field":""},{"help":"Postal or ZIP code","type":"text","label":"Postal code:","options":[],"required":true,"pdf_field":""},{"help":"Include country and area code if applicable","type":"phone","label":"Phone Number:","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email:","options":[],"required":true,"pdf_field":""},{"help":"Loan account number","type":"text","label":"Loan Details: Loan A/c no:","options":[],"required":true,"pdf_field":""},{"help":"Date format DD MM YYYY","type":"date","label":"Loan Start Date:","options":[],"required":true,"pdf_field":""},{"help":"Loan tenure","type":"text","label":"Tenure:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of Bank/ Financial Institution:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address of Bank / Institution:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"Section C – Benefit being claimed for","fields":[{"help":"Select place of treatment; specify location if outside India","type":"choice","label":"Place of treatment: Within India Outside India (Please specify the location):","options":["Within India","Outside India"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of hospital where hospitalized:","options":[],"required":true,"pdf_field":""},{"help":"Include landmark, country, town/city, postal code","type":"text","label":"Address of the hospital:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Landmark:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Country:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Town/City:","options":[],"required":true,"pdf_field":""},{"help":"Postal or ZIP code","type":"text","label":"Postal Code:","options":[],"required":true,"pdf_field":""},{"help":"Describe the accident or event","type":"text","label":"Details of the accident/event:","options":[],"required":true,"pdf_field":""},{"help":"Select one","type":"choice","label":"Hospitalization due to: Injury Illness","options":["Injury","Illness"],"required":true,"pdf_field":""},{"help":"Date format DD MM YYYY","type":"date","label":"Date of injury:","options":[],"required":true,"pdf_field":""},{"help":"Date format DD MM YYYY","type":"date","label":"Date of admission:","options":[],"required":true,"pdf_field":""},{"help":"Tick appropriate boxes","type":"checkbox","label":"Medico-legal: (i)Yes No (ii) Reported to police: Yes No (iii) MLC & FIR attached: Yes No","options":["Medico-legal Yes","Medico-legal No","Reported to police Yes","Reported to police No","MLC & FIR attached Yes","MLC & FIR attached No"],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"Section D – Details of claim","fields":[{"help":"Tick all documents submitted","type":"checkbox","label":"Claim documents submitted – checklist","options":["Duly signed claim Form","Copy of the claim intimation, if any","Hospital main bill","FIR from police authorities, wherever necessary (in case of accidents outside residence)","Death certificate from the municipal authorities and death summary from hospital authorities","Post mortem report (if conducted)","Inquest report/panchnama","Coroner’s report/forensic science laboratory report (if available)","Fitness certificate (if available)","Any other document(s) required for assessment of claim as per benefit opted"],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"Section E – Details of assistance services","fields":[{"help":"Tick if applicable","type":"checkbox","label":"Emergency medical evacuation:","options":["Yes"],"required":false,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Medical repatriation:","options":["Yes"],"required":false,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Repatriation of mortal remains:","options":["Yes"],"required":false,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Compassionate (parental/spouse accommodation):","options":["Yes"],"required":false,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"Section F – Details of bank account of insured person/nominee/legal heir","fields":[{"help":"Permanent Account Number","type":"text","label":"PAN:","options":[],"required":true,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"Bank account No:","options":[],"required":true,"pdf_field":""},{"help":"Name and branch of bank","type":"text","label":"Bank name and branch:","options":[],"required":true,"pdf_field":""},{"help":"Name to which cheque or demand draft is payable","type":"text","label":"Cheque/DD Payable details:","options":[],"required":true,"pdf_field":""},{"help":"Indian Financial System Code of bank branch","type":"text","label":"IFSC:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"Section G – Declaration by the insured person/claimant","fields":[{"help":"Date of signing, format DD MM YYYY","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the insured /claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"}],"deadlines":[],"applies_to":"","attachments":["Duly signed claim Form","Copy of the claim intimation, if any","Hospital main bill","FIR from police authorities, wherever necessary (in case of accidents outside residence)","Death certificate from the municipal authorities and death summary from hospital authorities","Post mortem report (if conducted)","Inquest report/panchnama","Coroner’s report/forensic science laboratory report (if available)","Fitness certificate (if available)","Any other document(s) required for assessment of claim as per benefit opted"],"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 is made, or material fact is concealed, the right to claim reimbursement shall be forfeited.","I consent and authorize the Company, its authorized TPA and ASP to seek necessary medical information/documents from any hospital/medical practitioner who attended the person against whom this claim is made.","I declare that I have included all bills/receipts/documents for this claim and will not make any supplementary claim.","I authorize Zuno General Insurance / Zuno authorized TPA to collect relevant medical documents from the treatment provider."],"dropped_labels":7},"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/1459-zuno-group-total-protect-policy-claim-form"}