{"id":1495,"title":"Zuno Empower Health Claim Form A V.1","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_4d4786d073.pdf?updated_at=2026-03-15T17:07:19.678Z","sha256":"8c6c009a640c92a360dcd3137d6024efd55bbc96da9ca096a2b6477fb7f8669b","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim health insurance benefits under the Zuno Empower Health policy.","notes":["Fill the form in BLOCK letters.","This form is not an admission of liability.","Enter dates in DDMMYYYY format unless otherwise specified.","Enter amounts in rupees without paise values.","Use the checklist to submit all required documents.","If claim is for domiciliary hospitalization, provide details in annexure."],"title":"Zuno Empower Health Claim Form A V.1","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section A – Details of primary insured","fields":[{"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":"Enter the policy number as allotted by the insurance company","type":"text","label":"a) Policy No:","options":[],"required":null,"pdf_field":""},{"help":"If applicable, enter the insurance company name","type":"text","label":"If yes, company name:","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number of other insurance if opted","type":"text","label":"Policy number:","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured in rupees","type":"amount","label":"Sum insured (INR):","options":[],"required":null,"pdf_field":""},{"help":"Enter date in DDMMYYYY 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:- Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of other insurance policy if applicable","type":"text","label":"If yes, please specify the details.","options":[],"required":null,"pdf_field":""},{"help":"Enter name of other insurance company","type":"text","label":"Name of the insurance compan :","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number of other insurance","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured under other policy","type":"amount","label":"Sum insured:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed under other policy","type":"amount","label":"Claimed amount:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Are you currently covered by any other mediclaim/ health insurance: Yes","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full name of the patient","type":"text","label":"a) Name:","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct gender","type":"choice","label":"b) Gender: Male","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"d) Age: Y Y Years M M Months","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth in DDMMYYYY format","type":"date","label":"e) Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct relationship or specify if Other","type":"choice","label":"Relationship with Primarily Insured: Self Spouse Child Father Mother Other (Please Specify)","options":["Self","Spouse","Child","Father","Mother","Other"],"required":null,"pdf_field":""},{"help":"Tick the correct occupation or specify if Other","type":"choice","label":"Occupation: Service Self-employed Homemaker Student Retired Other (Please Specify)","options":["Service","Self-employed","Homemaker","Student","Retired","Other"],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section D - Details of hospitalization","fields":[{"help":"Enter date of admission in DDMMYYYY format","type":"date","label":"Date of admission:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of discharge in DDMMYYYY 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: Self Inflicted","options":["Self Inflicted","Other"],"required":null,"pdf_field":""},{"help":"Enter time in HHMM format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No for medico legal and police report","type":"choice","label":"h) If medico legal: (i)Yes No (ii) Reported to Police: Yes No","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section G - Details in case of non-network hospital","fields":[{"help":"Enter Permanent Account Number","type":"text","label":"a) PAN:","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name and branch","type":"text","label":"c) Bank name and branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary for cheque/DD","type":"text","label":"d) Cheque/DD payable details:","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"e) IFSC code:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section E – Details of claim","fields":[{"help":"Enter amounts in rupees for: Pre-hospitalization, Hospitalization, Post-hospitalization, Health-Check-up, Ambulance Charges, Others (code), Total, Pre-hospitalization period (days), Post-hospitalization period (days)","type":"table","label":"a) Details of the treatment expenses claimed","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"b) Claim for Domiciliary Hospitalization: Yes No (If Yes, provide details in annexure)","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, Total","type":"table","label":"c) Details of Lump sum / cash benefit claimed","options":[],"required":null,"pdf_field":""},{"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":"Fill details of bills enclosed with date and amount in rupees","type":"table","label":"Sr.No. Bill No. Date Issued by Towards Amount (INR)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section H - Declaration by the insured","fields":[{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the member","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"}],"deadlines":[],"applies_to":"health insurance claims under Zuno Empower Health policy","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","Pharmacy Bill","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 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 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 will be made.","I authorize Zuno General Insurance / Zuno authorized TPA to collect relevant medical documents for my claim."],"dropped_labels":0},"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/1495-zuno-empower-health-claim-form-a-v-1"}