{"id":1515,"title":"Health Insurance Policy Claim Form","purpose":"claim","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/Health_Insurance_Part_A_Claim_Form_ZK_26_27_v1_09042026_7b27f52924.pdf","sha256":"0221dd57ff00346e2c168c8d80f569106ab8565474075715c9c02dbdec609573","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person to claim health insurance benefits by providing details of insurance history, hospitalisation, treatment expenses, and bank details.","notes":["Fill the form in block letters.","Use original bills only.","Use dd-mm-yyyy format for dates unless otherwise specified.","Include STD code with phone numbers.","Do not enter paise values in amounts.","If 'Other' is selected in choices, specify details clearly.","Attach all relevant documents as per the checklist."],"title":"Health Insurance Policy Claim Form","submit":{"to":"Zurich Kotak General Insurance Company (India) Limited","how":"","address":"401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai - 400063. Maharashtra, India"},"purpose":"claim","sections":[{"title":"Details of Insurance History","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"a) Currently covered by any other Mediclaim / Health Insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"b) Date of commencement of first Insurance without break","options":[],"required":null,"pdf_field":""},{"help":"Name of the Insurance Company in full","type":"text","label":"c) If Yes, Company Name","options":[],"required":null,"pdf_field":""},{"help":"As allotted by the Insurance Company","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"In Rupees","type":"amount","label":"Sum Insured (`)","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"d) Have you been hospitalised in the last four years since inception of the contract?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use 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":"yes-no","label":"e) Previously covered by any other Mediclaim / Health Insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of the Insurance Company in full","type":"text","label":"f) If Yes, Company Name","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Primary Insured","fields":[{"help":"As allotted by the insurance company","type":"text","label":"a) Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Social insurance or certificate number","type":"text","label":"b) Sl. No./Certificate No","options":[],"required":null,"pdf_field":""},{"help":"As per TPA documents","type":"text","label":"c) Company / TPA ID No.","options":[],"required":null,"pdf_field":""},{"help":"Full name of the primary insured","type":"text","label":"d) Name","options":[],"required":null,"pdf_field":""},{"help":"Full postal address including city, state, and pin code","type":"text","label":"e) Address","options":[],"required":null,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"f) Phone No","options":[],"required":null,"pdf_field":""},{"help":"Complete email address","type":"email","label":"g) Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Insured Person Hospitalised","fields":[{"help":"Surname, First Name, Middle Name","type":"text","label":"a) Name","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"b) Gender","options":["Male","Female","Others"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"c) Age","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"d) Date of birth","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate relationship or specify if Other","type":"choice","label":"e) Relationship to Primary Insured","options":["Self","Spouse","Child","Father","Mother","Other (Please specify)"],"required":null,"pdf_field":""},{"help":"Tick the appropriate occupation or specify if Other","type":"choice","label":"f) Occupation","options":["Service","Self Employed","Homemaker","Student","Retired","Other"],"required":null,"pdf_field":""},{"help":"Full postal address including city, state, and pin code","type":"text","label":"g) Address (If different from above)","options":[],"required":null,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"h) Phone No","options":[],"required":null,"pdf_field":""},{"help":"Complete email address","type":"email","label":"i) Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Hospitalisation","fields":[{"help":"Full name of the hospital","type":"text","label":"a) Name of the Hospital where Admitted","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate room category","type":"choice","label":"b) Room Category occupied","options":["Day care","Single occupancy","Twin sharing","3 or more beds per room","ICU"],"required":null,"pdf_field":""},{"help":"Tick the appropriate reason","type":"choice","label":"c) Hospitalisation due to","options":["Illness","Injury","Maternity","Self Inflicted","Road Traffic Accident","Substance Abuse/ Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"Specify cause of injury if applicable","type":"text","label":"i) If Injury give cause","options":[],"required":null,"pdf_field":""},{"help":"Enter the system of medicine followed","type":"text","label":"j) System of Medicine","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"d) Date of Injury/ Date Disease first detected / Date of Delivery","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"e) Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"f) Time","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"g) Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"h) Time","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"i) If Medico legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"ii) Reported to Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"iii) MLC Report & Police FIR Attached","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claim","fields":[{"help":"Enter amounts in Rupees for: i) Pre-hospitalisation Expenses, ii) Hospitalisation Expenses, iii) Post hospitalisation Expenses, iv) Health Check-up Cost, v) Ambulance Charges, vi) Others (Code), and total","type":"table","label":"a) Details of Treatment Expenses Claimed","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"vii) Pre hospitalisation Period","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"viii) Post hospitalisation Period","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"b) Claim for Domiciliary Hospitalisation","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amounts in Rupees for: i) Hospital Daily Cash, ii) Surgical Cash, iii) Critical Illness Benefit, iv) Convalescence, vi) Others (provide details in Annexure), and total","type":"table","label":"c) Details of Lump Sum / Cash Benefit Claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Bills Enclosed","fields":[{"help":"Number of hospital main bills enclosed","type":"number","label":"Hospital Main Bill","options":[],"required":null,"pdf_field":""},{"help":"Number of pre-hospitalisation bills enclosed","type":"number","label":"Pre-hospitalisation Bills","options":[],"required":null,"pdf_field":""},{"help":"Number of post-hospitalisation bills enclosed","type":"number","label":"Post-hospitalisation Bills","options":[],"required":null,"pdf_field":""},{"help":"List pharmacy bills with details","type":"table","label":"Pharmacy Bills","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Primary Insured’s Bank Account","fields":[{"help":"Permanent Account Number as allotted by Income Tax Department","type":"text","label":"a) PAN","options":[],"required":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"b) Account Number","options":[],"required":null,"pdf_field":""},{"help":"Full name of bank and branch","type":"text","label":"c) Bank Name and Branch","options":[],"required":null,"pdf_field":""},{"help":"Name of beneficiary to whom cheque/DD should be made payable","type":"text","label":"d) Cheque/DD Payable Details","options":[],"required":null,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"e) IFSC Code","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by Insured","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"","attachments":["Claim Form Duly Signed","Copy of the Claim Intimation, if any","Hospital Main Bill","Hospital Break-up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","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.","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.","All bills/receipts for the purpose of this claim are included and no supplementary claim will be made except pre/post-hospitalisation claim, if any."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Family Health Plan Insurance TPA Limited, Srinilaya – Cyber Spazio, Suite # 101,102,109&110, Ground Floor,Road No. 2, Banjara Hills, Hyderabad : 500034, Telangana , India","label":"Health claims department address","level":null,"hours":null,"applies_to":"health","source_url":"https://www.zurichkotak.com/services/claims","quote":"g address as early as possible, but no later than 30 days from the date of discharge.\nHealth claims department address:\nFamily Health Plan Insurance TPA Limited, Srinilaya – Cyber Spazio, Suite # 101,102,109&110, Ground Floor,Road No. 2, Banjara Hills, Hyderabad : 500034, Telangana , India\nIs there any time period for filing pre and post hospital claims?\nThe pre-hospitalisation claim documents duly complete","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"care@zurichkotak.com","label":"Email Address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.zurichkotak.com/services/claims","quote":"in\nToll Number (INDIA And Overseas)\n+91-22-69417220\nToll Free Number\n1800 2120\nWhatsApp Number\n7998879988\nEmail Address\ncare@zurichkotak.com\nOur WhatsApp number cannot be used for calls. This is chat only number.\nAccessibility\nZoom in page\nZoom out page\nIncrea","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 2120","label":"Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.zurichkotak.com/services/claims","quote":"age claims\nCustomer support\nGrievance redressal\nLogin\nToll Number (INDIA And Overseas)\n+91-22-69417220\nToll Free Number\n1800 2120\nWhatsApp Number\n7998879988\nEmail Address\ncare@zurichkotak.com\nOur WhatsApp number cannot be used for calls. This is cha","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+91-22-69417220","label":"Toll Number (INDIA And Overseas)","level":null,"hours":"IST 8 am to 8 pm","applies_to":"all","source_url":"https://www.zurichkotak.com/services/claims","quote":"Download policy\nManage policy\nManage claims\nCustomer support\nGrievance redressal\nLogin\nToll Number (INDIA And Overseas)\n+91-22-69417220\nToll Free Number\n1800 2120\nWhatsApp Number\n7998879988\nEmail Address\ncare@zurichkotak.com\nOur WhatsApp number cannot be","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/zurich-kotak-general-insurance/1515-health-insurance-policy-claim-form"}