{"id":1461,"title":"Saral Suraksha Bima, Zuno General Insurance Limited Claim Form","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Saral_Suraksha_Bima_Claim_form_V_1_1_1374ba925d.pdf?updated_at=2024-09-26T06:02:56.633Z","sha256":"3824802465eaac3810c090b7d5f5e0b9899b4e63ca00b4174080e39e1d6b4e6a","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for insured persons or claimants to file a claim under the Saral Suraksha Bima insurance policy with Zuno General Insurance Limited.","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.","The issuing of this form does not imply acceptance of liability."],"title":"Saral Suraksha Bima, Zuno General Insurance Limited Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"SECTION A – DETAILS OF THE INSURED PERSON","fields":[{"help":"","type":"text","label":"Master Policy No.:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Certificate No.:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Company/TPA/ASP/Policyholder issued ID card no.:","options":[],"required":true,"pdf_field":""},{"help":"Fill in BLOCK LETTERS","type":"text","label":"Name of Insured Person:","options":[],"required":true,"pdf_field":""},{"help":"Specify type of photo identity proof","type":"text","label":"Photo identity proof:","options":[],"required":true,"pdf_field":""},{"help":"Provide number if applicable","type":"text","label":"Passport / Identity document Number: (wherever applicable)","options":[],"required":true,"pdf_field":""},{"help":"Fill full address details","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":"Nearest landmark to address","type":"text","label":"Landmark:","options":[],"required":true,"pdf_field":""},{"help":"PIN 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":"Valid email address","type":"email","label":"Email:","options":[],"required":true,"pdf_field":""},{"help":"Date when insured joined company or association","type":"date","label":"Date of Joining/Associating:","options":[],"required":true,"pdf_field":""},{"help":"Name of employer if employed","type":"text","label":"Name of Company (if applicable, as an employee):","options":[],"required":true,"pdf_field":""},{"help":"Employee identification number","type":"text","label":"Employee No.:","options":[],"required":true,"pdf_field":""},{"help":"Branch of employer","type":"text","label":"Branch Location:","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Have you opted for benefits under a different insurance policy:","options":["Yes","No"],"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 insurer 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 B – DETAILS OF THE INSURED PERSON(S) / CLAIMANTS MAKING THIS CLAIM","fields":[{"help":"Name of claimant or insured person","type":"text","label":"Name of the Insured Person/ Claimant:","options":[],"required":true,"pdf_field":""},{"help":"Number of photo ID card","type":"text","label":"Photo Identity Card Number:","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender:","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Age in years and months","type":"number","label":"Age:","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of claimant","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Select relationship","type":"choice","label":"Relationship with Primary Insured:","options":["Self","Spouse","Child","Father","Mother","Other (Please Specify)"],"required":true,"pdf_field":""},{"help":"Select occupation","type":"choice","label":"Occupation:","options":["Service","Self-employed","Homemaker","Student","Retired","Other (Please Specify)"],"required":true,"pdf_field":""},{"help":"Fill full address if different","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":"Nearest landmark","type":"text","label":"Landmark:","options":[],"required":true,"pdf_field":""},{"help":"PIN or ZIP code","type":"text","label":"Postal Code:","options":[],"required":true,"pdf_field":""},{"help":"Contact phone number","type":"phone","label":"Phone Number:","options":[],"required":true,"pdf_field":""},{"help":"Contact email","type":"email","label":"Email:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"SECTION C – THE BENEFIT BEING CLAIMED FOR","fields":[{"help":"Select place of treatment and specify location if outside India","type":"choice","label":"Place of Treatment:","options":["Within India","Outside India (Please specify the location)"],"required":true,"pdf_field":""},{"help":"Hospital name","type":"text","label":"Name of Hospital where Hospitalized:","options":[],"required":true,"pdf_field":""},{"help":"Full hospital address","type":"text","label":"Address of the Hospital:","options":[],"required":true,"pdf_field":""},{"help":"Nearest landmark to hospital","type":"text","label":"Landmark:","options":[],"required":true,"pdf_field":""},{"help":"Country of hospital","type":"text","label":"Country:","options":[],"required":true,"pdf_field":""},{"help":"City of hospital","type":"text","label":"Town/ City:","options":[],"required":true,"pdf_field":""},{"help":"Postal code of hospital","type":"text","label":"Postal Code:","options":[],"required":true,"pdf_field":""},{"help":"Describe accident or event causing claim","type":"text","label":"Details of the Accident/event:","options":[],"required":true,"pdf_field":""},{"help":"Select cause of hospitalization","type":"choice","label":"Hospitalization due to:","options":["Injury","Illness"],"required":true,"pdf_field":""},{"help":"Date when injury occurred","type":"date","label":"Date of Injury:","options":[],"required":true,"pdf_field":""},{"help":"Date admitted to hospital","type":"date","label":"Date of Admission:","options":[],"required":true,"pdf_field":""},{"help":"Date discharged from hospital","type":"date","label":"Date of Discharge:","options":[],"required":true,"pdf_field":""},{"help":"Select cause of injury","type":"choice","label":"If due to injury, give cause:","options":["Self-inflicted","Road Traffic Accident","Substance Abuse/Alcohol Consumption"],"required":true,"pdf_field":""},{"help":"Indicate Yes or No for each medico-legal question","type":"text","label":"Medico-legal: (i)Yes No (ii) Reported to Police: Yes No (iii) MLC & FIR attached: Yes No","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"SECTION D – DETAILS OF CLAIM","fields":[{"help":"List benefits claimed with details","type":"text","label":"Name of benefits claimed with details:","options":[],"required":true,"pdf_field":""},{"help":"Total claimed amount in rupees","type":"amount","label":"Total: Rs","options":[],"required":true,"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":"Account number for claim payment","type":"text","label":"Bank Account Number:","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 on cheque or demand draft","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"}],"deadlines":[],"applies_to":"claims under Saral Suraksha Bima policy","attachments":["Duly filled and signed Claim Form","Photo ID proof of insured and/or nominee or legal heir","Death Certificate (issued by local administrative authorities, if applicable)","Post Mortem Report (if conducted)","Copy of FIR/ Panchnama /Police Inquest Report (wherever these reports are required as per the circumstance of the Accident) duly attested by the concerned Police Station","Copy of Medico Legal Certificate (wherever it is required as per the circumstance of the Accident) duly attested by the concerned Hospital","Original treating Medical Practitioner’s certificate describing the disablement","Original Discharge Summary from the Hospital","Any other medical, investigation reports, inpatient or consultation treatment papers, as applicable","Leave/Absence Certificate from the Employer (If Employed)","Medical Practitioner’s Certificate confirming the Injury and advising rest/confirming unfit to work for a specified number of days","Fitness Certificate issued by the treating Doctor","Medical & investigation reports","Prescriptions and consultation papers of the treatment","Proof to establish relationship – Passport/Education certificate establishing proof of relationship of Child with Parents / Birth Certificate","Photo Identity Proof of Child along with age proof","Original Bonafide Certificate issued by the educational institution confirming that he/she is a full time student of the institution"],"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.","Consent is given to the Company and its authorized TPA to seek necessary medical information/documents from any hospital/medical practitioner who attended the person for whom this claim is made.","All bills/receipts/available documents for the claim are included and no supplementary claim will be made.","Authorization is given to Zuno General Insurance / Zuno authorized TPA to collect relevant medical documents for the claim from the treatment provider."],"dropped_labels":1},"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/1461-saral-suraksha-bima-zuno-general-insurance-limited-claim-form"}