{"id":1493,"title":"Zuno Arogya Sanjeevani Policy Claim Form A V-1.2","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Arogya_Sanjeevani_Policy_Claim_Form_A_V_1_2_e40ff9eb1c.pdf?updated_at=2026-03-15T17:05:16.451Z","sha256":"2952e0b9a2fa8a69d63be4d996bc6e2e9236f5d8b6253a3c6cd095d8e4c32a5f","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for policyholders to claim health insurance benefits under the Arogya Sanjeevani Policy from Zuno General Insurance Limited.","notes":["Use dd-mm-yy or DDMMYYYY format for dates as specified.","Enter amounts in rupees only, do not enter paise values.","Tick the appropriate options where indicated.","Attach original bills and documents as per checklist.","This form is to be filled by the insured (policyholder).","Office use only sections are excluded."],"title":"Zuno Arogya Sanjeevani Policy Claim Form A V-1.2","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section a - Details of primary insured","fields":[{"help":"Enter the policy number 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":"Sl. No ./ Certificate No:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the policyholder (Surname, First name, Middle name)","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address including Street, City, State, 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":"Enter phone number including STD code","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section b - Details of insurance history","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Currently covered by any other mediclaim/ health insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full name of other insurance company if currently covered","type":"text","label":"If yes, company name:","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number of other insurance if currently covered","type":"text","label":"Policy number:","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured amount in rupees","type":"amount","label":"Sum insured (INR):","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Previously covered by any other mediclaim / health insurance?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full name of previous insurance company if applicable","type":"text","label":"If yes, company name:","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section c - Details of insured person hospitalized","fields":[{"help":"Enter full name of the 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","type":"number","label":"Age:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth in DDMMYYYY format","type":"date","label":"Date of birth:","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate relationship","type":"choice","label":"Relationship with primarily insured:","options":["Self"],"required":null,"pdf_field":""},{"help":"Tick the appropriate occupation","type":"choice","label":"Occupation:","options":["Service","Self-employed","Homemaker"],"required":null,"pdf_field":""},{"help":"Enter full postal address including pin code","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number including STD code","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section d - Details of hospitalization","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":"Enter date in DDMMYYYY format","type":"date","label":"Date of Injury / date disease first detected /date of delivery:","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date of admission:","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission in HHMM format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date of discharged:","options":[],"required":null,"pdf_field":""},{"help":"Enter time of discharge in HHMM format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate cause","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":"yes-no","label":"If medico legal: (i)Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"(ii) Reported to Police: Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"iii) MLC report & police FIR attached: Yes No","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section e - Details of claim","fields":[{"help":"Enter amounts in rupees for: Pre-hospitalization, Hospitalization, Post-hospitalization, Health-check-up cost, Ambulance charges, Others (code), and total","type":"table","label":"Details of the treatment expenses claimed","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Pre-hospitalization period:","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Post-hospitalization period:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Claim for domiciliary hospitalization:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amounts in rupees for Hospital daily cash, Surgical cash, Critical illness benefit, Convalescence, Pre/Post hospitalization lump sum benefit, Others, and total","type":"table","label":"Details of lump sum / cash benefit claimed","options":[],"required":null,"pdf_field":""},{"help":"Tick the documents submitted as per checklist","type":"checkbox","label":"Claim documents submitted – checklist","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section g - Details in case of non-network hospital","fields":[{"help":"Enter Permanent Account Number as allotted 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 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","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Section h - Declaration by the insured","fields":[{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":[],"applies_to":"Arogya Sanjeevani Policy health insurance claims","attachments":["MLC report & police FIR (if medico legal injury)","Claim documents as per checklist","Bills for hospitalization, pre- and post-hospitalization, pharmacy, and others"],"declarations":["The form is not an admission of liability.","The insured must read and sign the declaration in Section h."],"dropped_labels":2},"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/1493-zuno-arogya-sanjeevani-policy-claim-form-a-v-1-2"}