{"id":1488,"title":"Zuno Group Health Insurance Policy Claim Form - A","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Group_Health_Insurance_Policy_Claim_form_A_V_2_0_6aca799cc7.pdf","sha256":"6e5d2eae818082d2901bcff8a9e9c39a7a019da7635b10044b49bed3ba533d88","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim health insurance benefits under the Zuno Group Health Insurance Policy.","notes":["Fill all details in BLOCK LETTERS.","This form should be filled in by the insured person.","This form is not an admission of liability.","Use original bills only.","Use specified date formats as indicated in each section.","Tick the appropriate options where applicable."],"title":"Zuno Group Health Insurance Policy Claim Form - A","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section A – Some details about your policy","fields":[{"help":"Enter the policy number as allotted by the insurance company","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter the social insurance number or certificate number","type":"text","label":"Serial No / Certificate 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 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":"","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 with telephone number","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of corporate:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Employee No:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Branch location:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section B – Share your past/other insurance information","fields":[{"help":"Tick Yes or No","type":"choice","label":"Are you currently covered by any other mediclaim / health insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of beginning of the first insurance without break:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"If Yes, company name:","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"Enter 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 the start of the policy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use mm-yy 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":"Have you opted for benefits under a different insurance policy:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If yes, please specify the details.","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"Name of the insurance company:","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured in rupees","type":"amount","label":"Sum insured:","options":[],"required":null,"pdf_field":""},{"help":"Enter claimed amount in rupees","type":"amount","label":"Claimed amount:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section C – A bit about the person hospitalized","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of birth:","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option 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 right option 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 including street, city, and 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 with telephone number","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section D – details of hospitalization","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of hospital admitted:","options":[],"required":null,"pdf_field":""},{"help":"Enter full address of hospital","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Landmark:","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Room category opted for:","options":["Day care","Single occupancy","Twin sharing","3 or more beds per room"],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Hospitalization due to:","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Injury / date disease first detected /date of delivery:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of admission:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of discharged:","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"If injury, give cause:","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":"(ii) Reported to Police: Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"iii) MLC report & police FIR attached: Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter system of medicine followed","type":"text","label":"System of medicine:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section E – What do we need for your claim?","fields":[{"help":"Columns: Pre-hospitalization expenses, Hospitalization expenses, Post-hospitalization expenses, Health-check-up cost, Ambulance charges, OPD, Total, Pre-hospitalization period (days), Post-hospitalization period (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":"choice","label":"Claim for domiciliary hospitalization:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Columns: Hospital daily cash, Surgical cash, Critical illness benefit, Convalescence, Pre/Post hospitalization lump sum benefit, Others, Total","type":"table","label":"Details of lump sum / cash benefit claimed","options":[],"required":null,"pdf_field":""},{"help":"Tick the documents you are submitting","type":"checkbox","label":"Claim documents submitted – checklist","options":["Duly signed claim Form","ECG","Copy of the claim intimation, if any","Doctor's request for investigation","Hospital main bill","Investigation reports (Including CT/MRI/USG/HPE)","Hospital break-up bill","Doctor’s prescriptions","Hospital release in short","Hospital Bill Payment Receipt","Pharmacy Bill","Operation Theatre Notes"],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section F – Details of bills enclosed","fields":[{"help":"Columns: Sl.No., Bill No., Date (DD/MM/YYYY), Issued by, Towards, Amount (₹)","type":"table","label":"Details of bills enclosed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section G - In case it’s an accident (tick the right option)","fields":[{"help":"Tick if applicable","type":"checkbox","label":"Death","options":[],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Permanent partial disability","options":[],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Permanent total disability","options":[],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Temporary total disability","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section H - Tell us more about the accident","fields":[{"help":"Use dd-mm-yy format & HH:MM","type":"date","label":"Date and time of accident:","options":[],"required":null,"pdf_field":""},{"help":"Mention place of accident","type":"text","label":"Place of accident:","options":[],"required":null,"pdf_field":""},{"help":"Mention cause of accident","type":"text","label":"Cause of accident:","options":[],"required":null,"pdf_field":""},{"help":"Mention if any","type":"text","label":"Temporary total disability:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section I - The insured’s or nominee’s bank account details","fields":[{"help":"Enter Permanent Account Number as given by Income Tax department","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 bank name and branch in full","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 J - Details of out-patient cover","fields":[{"help":"Use dd-mm-yy format","type":"date","label":"Treatment start date:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Treatment end date:","options":[],"required":null,"pdf_field":""},{"help":"Enter name and contact details","type":"text","label":"Name and contact details of treating doctor:","options":[],"required":null,"pdf_field":""},{"help":"Enter name and address","type":"text","label":"Name and address of clinic / hospital:","options":[],"required":null,"pdf_field":""},{"help":"Enter name of disease or ICD code","type":"text","label":"Nature of illness / disease:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Consultation fees:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Pharmacy / investigations etc:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section K – Declaration by the insured / nominee","fields":[{"help":"Enter date of signing","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 or nominee"}],"deadlines":[],"applies_to":"Group health insurance policy claims","attachments":["Duly signed claim Form","ECG","Copy of the claim intimation, if any","Doctor's request for investigation","Hospital main bill","Investigation reports (Including CT/MRI/USG/HPE)","Hospital break-up bill","Doctor’s prescriptions","Hospital release in short","Hospital Bill Payment Receipt","Pharmacy Bill","Operation Theatre Notes"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim reimbursement.","I consent and authorize TPA/insurance company to seek necessary medical information from any hospital or medical practitioner.","I declare that all bills and receipts for this claim are included and no other claim except pre/post hospitalization will be made.","I authorize Zuno General Insurance / Zuno authorized TPA to collect relevant medical documents for my claim."],"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/1488-zuno-group-health-insurance-policy-claim-form-a"}