{"id":1502,"title":"Zuno Health top up insurance 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_Health_top_up_insurance_claim_form_A_V_1_484aaa234e.pdf?updated_at=2026-03-15T17:06:30.684Z","sha256":"5690ef84f5439de1d76b53007c3fc0a9bcf1dbde8d97b53ffac89495ebef9086","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for the insured or policyholder to claim health top-up insurance benefits from Zuno General Insurance Limited.","notes":["Fill the form in BLOCK letters.","Use original bills and documents as listed.","Enter dates in DDMMYYYY or DD-MM-YY format as specified.","Attach all relevant supporting documents and bills.","If claiming domiciliary hospitalization, provide details in annexure.","Provide bank details accurately for claim payment."],"title":"Zuno Health top up insurance claim form A- V.1","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policyholder and Insured Details","fields":[{"help":"Enter the policy number as given by the insurance company","type":"text","label":"a) Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the policyholder or patient","type":"text","label":"d) Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter Aadhaar number as given by UIDAI","type":"text","label":"e) Aadhaar:","options":[],"required":null,"pdf_field":""},{"help":"Enter city of postal address","type":"text","label":"f) Address- City:","options":[],"required":null,"pdf_field":""},{"help":"Enter state of postal address","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Enter landmark near address if any","type":"text","label":"Landmark:","options":[],"required":false,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin code:","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number with STD code","type":"phone","label":"Phone No.:","options":[],"required":false,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""},{"help":"If currently covered by other insurance, enter company name","type":"text","label":"If yes, company name:","options":[],"required":false,"pdf_field":""},{"help":"Enter other insurance policy number if applicable","type":"text","label":"Policy number:","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured under other policy","type":"amount","label":"Sum insured (INR):","options":[],"required":false,"pdf_field":""},{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date: D D M M Y Y Y Y","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":"If yes, specify other insurance company name","type":"text","label":"Name of the insurance compan :","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number of other insurance","type":"text","label":"h) Policy No:","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured under other policy","type":"amount","label":"Sum insured:","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed under other policy","type":"amount","label":"Claimed amount:","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Are you currently covered by any other mediclaim/ health insurance: Yes","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick appropriate gender","type":"choice","label":"c) Gender: Male Female Third gender","options":["Male","Female","Third gender"],"required":null,"pdf_field":""},{"help":"Enter date of birth in DDMMYYYY format","type":"date","label":"e) Date of birth: D D M M Y  Y  Y  Y","options":[],"required":null,"pdf_field":""},{"help":"Tick relationship to primary insured","type":"choice","label":"f) Relationship with primarily insured: Self Spouse","options":["Self","Spouse"],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"d) Age:","options":[],"required":null,"pdf_field":""},{"help":"Tick occupation or specify if other","type":"choice","label":"g) Occupation: Service Self-employed Homemaker Other (please specify)","options":["Service","Self-employed","Homemaker","Other"],"required":null,"pdf_field":""},{"help":"Enter alternate city if different","type":"text","label":"h) Address (if different from above): city:","options":[],"required":false,"pdf_field":""},{"help":"Enter alternate state if different","type":"text","label":"State:","options":[],"required":false,"pdf_field":""},{"help":"Enter alternate pin code if different","type":"number","label":"Pin code:","options":[],"required":false,"pdf_field":""},{"help":"Enter alternate phone number if different","type":"phone","label":"i) Phone No.:","options":[],"required":false,"pdf_field":""},{"help":"Enter alternate email if different","type":"email","label":"j) Email ID:","options":[],"required":false,"pdf_field":""},{"help":"Tick room category occupied","type":"choice","label":"Room category occupied: Day care","options":["Day care","3 or more beds per room"],"required":null,"pdf_field":""},{"help":"Enter hospital address","type":"text","label":"Address:","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital landmark if any","type":"text","label":"Landmark:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section E – Details of claim","fields":[{"help":"Enter pre-hospitalization cost in rupees","type":"amount","label":"a) Details of the treatment being claimed for (i) Pre-hospitalization cost:","options":[],"required":null,"pdf_field":""},{"help":"Enter hospitalization cost in rupees","type":"amount","label":"(ii) Hospitalization cost:","options":[],"required":null,"pdf_field":""},{"help":"Enter post-hospitalization cost in rupees","type":"amount","label":"(iii) Post-hospitalization cost:","options":[],"required":null,"pdf_field":""},{"help":"Enter daycare cost in rupees","type":"amount","label":"(iv) Daycare:","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital cash claimed in rupees","type":"amount","label":"(v) Hospital cash being claimed:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount of co-pay support claimed","type":"amount","label":"(vi) Details of Base Policy Co-Pay Support claimed:","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days for pre-hospitalization","type":"number","label":"(vii) Pre-hospitalization period: days","options":[],"required":false,"pdf_field":""},{"help":"Enter amount of higher room rent deduction","type":"amount","label":"(viii) Details of Base Policy Higher room rent deduction:","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days for post-hospitalization","type":"number","label":"(ix) Post-hospitalization period: days","options":[],"required":false,"pdf_field":""},{"help":"Enter other expenses claimed with policy code","type":"amount","label":"(x) Others expenses claimed as per policy cover (code):","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no and attach annexure if yes","type":"yes-no","label":"b) Claim for Domiciliary Hospitalization: Yes No (If Yes, provide details in annexure)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter dental cover amount claimed","type":"amount","label":"c) Details of Dental Cover Claimed:","options":[],"required":false,"pdf_field":""},{"help":"Enter AYUSH hospitalization or daycare amount claimed","type":"amount","label":"d) Details of AYUSH Hospitalization or AYUSH Day care","options":[],"required":false,"pdf_field":""},{"help":"Enter expenses claimed under newborn cover","type":"amount","label":"e) Details of expenses under New Born baby cover:","options":[],"required":false,"pdf_field":""},{"help":"Enter vaccination expenses claimed under newborn cover","type":"amount","label":"f) Vaccination if opted for new born cover:","options":[],"required":false,"pdf_field":""},{"help":"List any additional supporting documents attached","type":"text","label":"g) Any additional / supporting documents:","options":[],"required":false,"pdf_field":""},{"help":"Enter total claim amount","type":"amount","label":"Total:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Details of bills enclosed","fields":[{"help":"Fill details of bills with columns: Sl.No, Bill No, Date (DD/MM/YYYY), Issued by, Towards, Amount in rupees","type":"table","label":"Sl.No. Bill No. Date Issued by Towards Amount (`)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Hospitalization details","fields":[{"help":"Enter date of admission in DDMMYYYY format","type":"date","label":"Date of admission: D D M M Y  Y  Y  Y","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission in HHMM format","type":"text","label":"Time: H H M M","options":[],"required":null,"pdf_field":""},{"help":"Enter date of discharge in DDMMYYYY format","type":"date","label":"Date of discharged: D D M M Y Y Y Y","options":[],"required":null,"pdf_field":""},{"help":"Enter time of discharge in HHMM format","type":"text","label":"Time: H H M M","options":[],"required":null,"pdf_field":""},{"help":"Tick cause of injury if applicable","type":"choice","label":"If injury, give cause: Self inflicted Road traffic accident","options":["Self inflicted","Road traffic accident"],"required":false,"pdf_field":""},{"help":"Tick if injury is medico legal and if reported to police","type":"choice","label":"h) If medico legal: (i)Yes No (ii) Reported to police: Yes","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Substance abuse/alcohol consumption","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Bank account details for claim payment","fields":[{"help":"Enter Permanent Account Number as per income tax department","type":"text","label":"a) PAN:","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"b) 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 or DD","type":"text","label":"Cheque/DD payable details:","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"e) IFSC:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / nominee"},{"title":"Declaration","fields":[{"help":"Enter date of signing in DDMMYYYY format","type":"date","label":"Date: D D M M Y Y Y Y","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / policyholder"}],"deadlines":[],"applies_to":"Zuno Health Top Up Insurance policies","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","Annexure for domiciliary hospitalization if applicable","Policy copy of the base policy"],"declarations":["The filling and submission of this form does not make the insurer liable to accept the claim.","The insured declares that the information provided is true and correct to the best of their knowledge."],"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/1502-zuno-health-top-up-insurance-claim-form-a-v-1"}