{"id":1472,"title":"Zuno Health Assure Insurance Claim Form A","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Health_Assure_Insurance_Claim_Form_A_14ee73d66b.pdf?updated_at=2025-03-25T05:42:17.161Z","sha256":"beabb41ee0cae84efcff00c1a83d438b8abdb6b2b6bf75e49fae413212ab8f51","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or policyholder to claim health insurance benefits for hospitalization and related medical expenses under the Zuno Health Assure Insurance policy.","notes":["Use dd-mm-yyyy format for dates unless otherwise specified.","Use hh:mm format for times.","Tick the appropriate options where indicated.","Include full postal addresses with street, city, and pin code.","Include STD code with telephone numbers.","Amounts should be entered in rupees; do not enter paise values.","If claiming domiciliary hospitalization, provide details in annexure.","This form is not an admission of liability.","Office use only sections are excluded from this form."],"title":"Zuno Health Assure Insurance Claim Form A","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section A – Details of the primary insured","fields":[{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Sl. No ./ Certificate No:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Company/ TPA ID No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of policyholder","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Include street, city, pin code","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Section B – Details of insurance history","fields":[{"help":"Tick Yes or No","type":"choice","label":"Currently covered by any other mediclaim/ health insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of commencement of first insurance without break:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of insurance company","type":"text","label":"If yes, company name:","options":[],"required":null,"pdf_field":""},{"help":"As allotted by the insurance company","type":"text","label":"Policy number:","options":[],"required":null,"pdf_field":""},{"help":"Enter total sum insured in rupees","type":"amount","label":"Sum insured (INR):","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Have you been hospitalized in the last four years since inception of the contract?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Previously covered by any other mediclaim / health insurance?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full name of insurance company","type":"text","label":"If yes, company name:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Section C – Details of insured person hospitalized","fields":[{"help":"Enter full name of patient","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 option or specify if Other","type":"choice","label":"Relationship with primarily insured:","options":["Self","Spouse","Mother","Father","Retired","Student","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Tick the appropriate option or specify if Other","type":"choice","label":"Occupation:","options":["Service","Self-employed","Homemaker","Retired","Student","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Include street, city, pin code","type":"text","label":"Address (if different from above):","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Section D – Details of hospitalization","fields":[{"help":"Enter full hospital name","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 Injury / date disease first detected /date of delivery:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of admission:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of discharged:","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 Yes or No","type":"choice","label":"If medico legal: (i)Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Reported to Police: Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"MLC report & police FIR attached: Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter system of medicine","type":"text","label":"System of medicine used for treatment:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Section E – Details of claim","fields":[{"help":"Enter amount in rupees","type":"amount","label":"Details of the treatment expenses claimed (i) Pre-hospitalization expenses:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"(ii) Hospitalization expenses:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"(iii) Post-hospitalization expenses:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"(iv) Health-check-up cost:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"(v) Ambulance charges:","options":[],"required":null,"pdf_field":""},{"help":"Specify code and amount","type":"text","label":"(vi) Others (code):","options":[],"required":null,"pdf_field":""},{"help":"Total amount claimed","type":"amount","label":"Total:","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"(vii) Pre-hospitalization period:","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"(viii) Post-hospitalization period:","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 in rupees","type":"amount","label":"Details of lump sum / cash benefit claimed (i) Hospital daily cash:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"(ii) Surgical cash:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"(iii) Critical illness benefit:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"(iv) Convalescence:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"(v) Pre/Post hospitalization lump sum benefit:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"(vi) Others:","options":[],"required":null,"pdf_field":""},{"help":"Total lump sum/cash benefit claimed","type":"amount","label":"Total:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Section G - Details of primarily insured’s bank account","fields":[{"help":"Permanent Account Number","type":"text","label":"PAN:","options":[],"required":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account No.:","options":[],"required":null,"pdf_field":""},{"help":"Full bank name and branch","type":"text","label":"Bank name and branch:","options":[],"required":null,"pdf_field":""},{"help":"Name of beneficiary for cheque/DD","type":"text","label":"Cheque/DD payable details:","options":[],"required":null,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"IFSC:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Section H – Declaration by the insured","fields":[{"help":"Use dd-mm-yyyy format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign to confirm declaration","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"","attachments":["Duly signed claim Form","Copy of the claim intimation, if any","Hospital main bill","Hospital break-up bill","Hospital discharge summary","Hospital bill payment receipt","Pharmacy bill","Operation theatre notes","ECG","Doctor's request for investigation","Investigation reports (Including CT/MRI / USG / HPE)","Doctor’s prescriptions","Others"],"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/documents from any hospital or medical practitioner who attended the person against whom this claim is made.","I declare that I have included all bills/receipts for this claim and will not make any supplementary claim except pre/post hospitalization claim, if any.","I authorize Zuno General Insurance / Zuno authorized TPA to collect relevant medical documents for my claim from the treatment provider."],"dropped_labels":3},"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/1472-zuno-health-assure-insurance-claim-form-a"}