{"id":1462,"title":"Claim Form - A","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Empower_Health_Claim_Form_A_V_1_1_04bc02f8e0.pdf?updated_at=2024-09-26T06:02:57.573Z","sha256":"d73d786d0a1f8c09750503adc0ed3d5ca460e667eec70e1d2011b92399c8bf40","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim health insurance benefits under their policy with Zuno General Insurance.","notes":["Fill the form in BLOCK letters.","This form is not an admission of liability.","Use dd-mm-yyyy format for dates and hh:mm for times.","Do not enter paise values in amounts.","If claiming domiciliary hospitalization, provide details in annexure.","Original bills and receipts should be attached as per checklist."],"title":"Claim Form - A","submit":{"to":"Zuno General Insurance Limited","how":"","address":"2nd Floor, Tower 3, Wing B, Kohinoor City Mall, Kohinoor City, Kirol Road, Kurla (West), Mumbai - 400 070"},"purpose":"claim","sections":[{"title":"General Information","fields":[{"help":"Enter the policy number","type":"text","label":"Policy No","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID number","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 full postal address including street, city, and pin code","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter 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":null,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section A – Details of primary insured","fields":[{"help":"Enter full name of the primary insured","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"Gender","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate 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 appropriate 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 from above","type":"text","label":"Address (if different from above)","options":[],"required":false,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Enter 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":"Enter valid email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section B – Some details of your other/past insurance","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Are you currently covered by any other mediclaim/ health insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"If yes, company name","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number of other insurance","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":"yes-no","label":"Have you been hospitalized in the last four years since the beginning of the policy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date of hospitalization in last four years","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 benefits","type":"text","label":"If yes, please specify the details","options":[],"required":false,"pdf_field":""},{"help":"Enter name of insurance company","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 person"},{"title":"Section C – Details of insured person hospitalized","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate 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-yyyy format","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission (hh:mm)","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of discharged","options":[],"required":null,"pdf_field":""},{"help":"Enter time of discharge (hh:mm)","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Tick the cause of injury","type":"choice","label":"If injury, what caused it","options":["Self Inflicted","Road Traffic Accident","Substance Abuse/Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"Tick appropriate options","type":"checkbox","label":"If medico legal: (i)Yes No (ii) Reported to Police: Yes No (iii) MLC Report & Police FIR attached: Yes No","options":["Medico legal Yes","Medico legal No","Reported to Police Yes","Reported to Police No","MLC Report & Police FIR attached Yes","MLC Report & Police FIR attached No"],"required":null,"pdf_field":""},{"help":"Enter system of medicine used","type":"text","label":"System of Medicine used for treatment","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section D – Details of hospitalization","fields":[{"help":"Enter amounts in rupees for: Pre-hospitalization Expenses, Hospitalization Expenses, Post-hospitalization Expenses, Health-Check-up Cost, Ambulance Charges, Others (code), Total; also pre and post hospitalization periods in days","type":"table","label":"Details of the treatment expenses claimed","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No; if Yes, provide details in annexure","type":"yes-no","label":"Claim for Domiciliary Hospitalization","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section E – Details of claim","fields":[{"help":"Tick all documents submitted","type":"checkbox","label":"Claim Documents Submitted – Checklist","options":["Signed Claim Form","Operation Theatre Notes","Copy of the claim intimation, if any","ECG","Hospital Main bill","Doctor's request for investigation","Hospital Break-up bill","Investigation Reports (Including CT/MRI / USG / HPE)","Hospital Discharge summary","Doctor’s Prescriptions","Hospital Bill Payment Receipt","Others","Pharmacy Bill"],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section F – Details of bills enclosed","fields":[{"help":"Enter serial number of bill","type":"number","label":"Sr.No.","options":[],"required":null,"pdf_field":""},{"help":"Enter bill number","type":"text","label":"Bill No.","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter name of issuer","type":"text","label":"Issued by","options":[],"required":null,"pdf_field":""},{"help":"Enter purpose of bill","type":"text","label":"Towards","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Amount (INR)","options":[],"required":null,"pdf_field":""},{"help":"Enter number of hospital main bills enclosed","type":"number","label":"Hospital main bill","options":[],"required":null,"pdf_field":""},{"help":"Enter number of pre-hospitalization bills enclosed","type":"number","label":"Pre-hospitalization bills: ___ Nos","options":[],"required":null,"pdf_field":""},{"help":"Enter number of post-hospitalization bills enclosed","type":"number","label":"Post-hospitalization bills: ___Nos","options":[],"required":null,"pdf_field":""},{"help":"Enter number of pharmacy bills enclosed","type":"number","label":"Pharmacy bills","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section G - Details of primarily insured’s bank account","fields":[{"help":"Enter Permanent Account Number","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 code","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section H - Declaration by the insured","fields":[{"help":"Sign the form","type":"signature","label":"Signature of the member","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing (dd-mm-yyyy)","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"}],"deadlines":[],"applies_to":"","attachments":["Signed Claim Form","Operation Theatre Notes","Copy of the claim intimation, if any","ECG","Hospital Main bill","Doctor's request for investigation","Hospital Break-up bill","Investigation Reports (Including CT/MRI / USG / HPE)","Hospital Discharge summary","Doctor’s Prescriptions","Hospital Bill Payment Receipt","Others","Pharmacy Bill"],"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 TPA/Insurer to seek necessary medical information/documents from any hospital or medical practitioner.","I declare that all bills/receipts for this claim are included and no other 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 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/1462-claim-form-a"}