{"id":1470,"title":"Zuno Group Janata Personal Accident Policy Claim Form","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Group_Janata_Personal_Accident_Policy_Claim_Form_V_1_1_8530a73682.pdf?updated_at=2024-09-26T12:15:12.171Z","sha256":"e5715c2b12ede2ebab2f5ce8adca4bfc1515ac6785bd859585151c3a8d137644","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person or claimant to file a claim under the Zuno Group Janata Personal Accident 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 and certificates as specified.","Check that all required documents are attached before submission."],"title":"Zuno Group Janata Personal Accident Policy Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"General Information","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":"Write full name 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 No: (wherever applicable)","options":[],"required":true,"pdf_field":""},{"help":"Fill full address including city, state, country, landmark, postal code","type":"text","label":"Address as per photo identity proof:","options":[],"required":true,"pdf_field":""},{"help":"City of address","type":"text","label":"City:","options":[],"required":true,"pdf_field":""},{"help":"State of address","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"Country of address","type":"text","label":"Country:","options":[],"required":true,"pdf_field":""},{"help":"Nearby landmark for address","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":"Contact phone number","type":"phone","label":"Phone No:","options":[],"required":true,"pdf_field":""},{"help":"Valid email address","type":"email","label":"Email:","options":[],"required":true,"pdf_field":""},{"help":"Date when insured joined the company or association","type":"date","label":"Date of joining/associating:","options":[],"required":true,"pdf_field":""},{"help":"Name of employer if applicable","type":"text","label":"Name of company (if applicable, as an employee):","options":[],"required":true,"pdf_field":""},{"help":"Employee number if applicable","type":"text","label":"Employee No:","options":[],"required":true,"pdf_field":""},{"help":"Branch location of employer","type":"text","label":"Branch location:","options":[],"required":true,"pdf_field":""},{"help":"Name of other insurance company if applicable","type":"text","label":"If yes, please specify the details. Name of the insurance company:","options":[],"required":true,"pdf_field":""},{"help":"Policy number of other insurance if applicable","type":"text","label":"Policy No:","options":[],"required":true,"pdf_field":""},{"help":"Sum insured under other policy if applicable","type":"amount","label":"Sum insured:","options":[],"required":true,"pdf_field":""},{"help":"Amount claimed under other policy if applicable","type":"amount","label":"Claimed amount:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"Section B – Who is the claim for?","fields":[{"help":"Full name in BLOCK LETTERS","type":"text","label":"Name of the insured person/ claimant:","options":[],"required":true,"pdf_field":""},{"help":"Number of photo identity card","type":"text","label":"Photo Identity card No:","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: years months","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 or specify if Other","type":"choice","label":"Relationship with primarily insured:","options":["Self","Spouse","Child","Father","Mother","Other: (please specify)"],"required":true,"pdf_field":""},{"help":"Select occupation or specify if Other","type":"choice","label":"Occupation:","options":["Service","Self-employed","Homemaker","Student","Retired","Other: (please specify)"],"required":true,"pdf_field":""},{"help":"Full current address if different from above","type":"text","label":"Current residential address (if different from above):","options":[],"required":true,"pdf_field":""},{"help":"City of current address","type":"text","label":"City:","options":[],"required":true,"pdf_field":""},{"help":"State of current address","type":"text","label":"State:","options":[],"required":true,"pdf_field":""},{"help":"Country of current address","type":"text","label":"Country:","options":[],"required":true,"pdf_field":""},{"help":"Postal code of current address","type":"text","label":"Postal code:","options":[],"required":true,"pdf_field":""},{"help":"Phone number at current address","type":"phone","label":"Phone No:","options":[],"required":true,"pdf_field":""},{"help":"Email address at current address","type":"email","label":"Email ID:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"Section C – What’s the benefit being claimed?","fields":[{"help":"Select place of treatment and specify location if outside India","type":"choice","label":"Place of treatment:","options":["Within India","Outside India"],"required":true,"pdf_field":""},{"help":"Specify location if outside India","type":"text","label":"Please specify the location:","options":[],"required":true,"pdf_field":""},{"help":"Name of hospital","type":"text","label":"Name of hospital where hospitalized:","options":[],"required":true,"pdf_field":""},{"help":"Full hospital address including landmark, country, town/city, postal code","type":"text","label":"Address of the hospital:","options":[],"required":true,"pdf_field":""},{"help":"Nearby landmark of hospital","type":"text","label":"Landmark:","options":[],"required":true,"pdf_field":""},{"help":"Country of hospital","type":"text","label":"Country:","options":[],"required":true,"pdf_field":""},{"help":"Town or 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 the accident or event causing injury","type":"text","label":"Details of the accident/event:","options":[],"required":true,"pdf_field":""},{"help":"Select reason for 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 of hospital admission","type":"date","label":"Date of admission:","options":[],"required":true,"pdf_field":""},{"help":"Date of hospital discharge","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 medico-legal status and police reporting","type":"checkbox","label":"Medico-legal: (i)Yes No (ii) Reported to police: Yes No (iii) MLC & FIR attached: Yes No","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"Section D – Details of claim","fields":[{"help":"Total amount claimed","type":"amount","label":"Total:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"},{"title":"Section E – Details of the bank account to pay your claim into","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 on cheque or demand draft payable","type":"text","label":"Cheque/DD Payable details:","options":[],"required":true,"pdf_field":""},{"help":"IFSC 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 declaration","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Place of signing declaration","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the insured /claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person/claimant"}],"deadlines":[],"applies_to":"claims under the Zuno Group Janata Personal Accident 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 employer (if employed)","Medical practitioner’s certificate confirming the injury and advising rest/ unfit to work for 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 of child","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.","I consent and authorize Zuno General Insurance Ltd., 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 agree to provide necessary assistance in relation to assessment and settlement of this claim.","I declare that I have included all bills, receipts, and available documents for this claim and will not make any supplementary claim.","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/1470-zuno-group-janata-personal-accident-policy-claim-form"}