{"id":32,"title":"ACKO GROUP HEALTH INSURANCE POLICY CLAIM FORM","purpose":"claim","insurer":{"slug":"acko-life-insurance","name":"Acko Life Insurance Limited"},"source_pdf":"https://acko-cms.ackoassets.com/Claim_Form_Acko_Group_Health_Insurance_Policy_f0ae948b40.pdf","sha256":"1bbfa948fa4332ed4f352605f1d4ae4033d67c0d828413f7321d6208a0273fb9","pages":9,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or claimant to submit a health insurance claim under the Acko Group Health Insurance Policy. It collects details about the policyholder, insured person, accident or hospitalization, benefits claimed, and bank details for claim payment. Part B is completed by the hospital.","notes":["Complete the form in CAPITAL LETTERS.","Do not leave any column unanswered; mention 'N/A' if not applicable.","Attach all original witness statements if already obtained.","Attach a copy of cancelled cheque and PAN card for EFT payment option.","Submission of this Claim Form is not to be taken as an admission of liability by Acko General Insurance Ltd."],"title":"ACKO GROUP HEALTH INSURANCE POLICY CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section I – To be completed by Insured Person/Claimant","fields":[{"help":"Enter the group name under which the policy is issued","type":"text","label":"Group Name","options":[],"required":true,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"Policy No","options":[],"required":true,"pdf_field":""},{"help":"Name of the policyholder","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter type of business of the policyholder","type":"text","label":"Type of Business","options":[],"required":false,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"City of residence","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"State of residence","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Postal PIN code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Telephone Number: Mobile","options":[],"required":true,"pdf_field":""},{"help":"Email address","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Currently covered by any other Health/Travel Insurance Policy (Y/N)","options":["Y","N"],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of commencement of first Insurance without break","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurer if currently covered","type":"text","label":"If yes, Company Name","options":[],"required":false,"pdf_field":""},{"help":"Policy number and sum insured of other policy","type":"text","label":"Policy No. and Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Have you been hospitalised in the last four years since inception of the contract (Y/N)","options":["Y","N"],"required":true,"pdf_field":""},{"help":"Diagnosis for previous hospitalisation if any","type":"text","label":"Diagnosis","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Previously covered by any other Health/Travel Insurance (Y/N)","options":["Y","N"],"required":true,"pdf_field":""},{"help":"Name of previous insurer if applicable","type":"text","label":"If yes, Company Name","options":[],"required":false,"pdf_field":""},{"help":"Name of the insured person for whom claim is made","type":"text","label":"Name of Primary Insured","options":[],"required":true,"pdf_field":""},{"help":"Name of person claiming","type":"text","label":"Name of claimant","options":[],"required":true,"pdf_field":""},{"help":"Occupation of claimant","type":"text","label":"Occupation","options":[],"required":false,"pdf_field":""},{"help":"Relationship of claimant to policyholder","type":"text","label":"Relationship with Policyholder","options":[],"required":true,"pdf_field":""},{"help":"Claimant's address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"City of claimant","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"State of claimant","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"PIN code of claimant","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Mobile number of claimant","type":"phone","label":"Telephone Number: Mobile","options":[],"required":true,"pdf_field":""},{"help":"Email of claimant","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Insurance certificate number","type":"text","label":"Certificate of Insurance No","options":[],"required":false,"pdf_field":""},{"help":"Mode of travel if applicable","type":"text","label":"Mode of Travel","options":[],"required":false,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Injury/Death","options":[],"required":false,"pdf_field":""},{"help":"Time of injury/death in HH:MM hrs","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"Location of incident","type":"text","label":"Place of Accident/Injury/Death","options":[],"required":false,"pdf_field":""},{"help":"Describe accident details","type":"text","label":"Details of Accident and Nature of Accident","options":[],"required":false,"pdf_field":""},{"help":"Describe loss details with date and location","type":"text","label":"Details of Loss (Date & Location)","options":[],"required":false,"pdf_field":""},{"help":"Describe inconvenience caused","type":"text","label":"Details of Inconvenience","options":[],"required":false,"pdf_field":""},{"help":"Details of any liability claim","type":"text","label":"Details of Liability Claim","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Did the Accident/ Loss/ Inconvenience happen when Insured Person was travelling in the covered mode of travel","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Whether reported to Police","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Police station details if reported","type":"text","label":"If Yes, Name and Address of Police Station","options":[],"required":false,"pdf_field":""},{"help":"Reason if not reported to police","type":"text","label":"If No, Give reasons","options":[],"required":false,"pdf_field":""},{"help":"FIR/MLC/Missing complaint number if applicable","type":"text","label":"First Information Report (FIR)/ Medico Legal Certificate (MLC)/ Missing complaint No.","options":[],"required":false,"pdf_field":""},{"help":"Date of FIR/MLC/Missing complaint","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Police station contact details","type":"text","label":"Contact Details of Police Station","options":[],"required":false,"pdf_field":""},{"help":"Name of travel carrier","type":"text","label":"Name of the Carrier","options":[],"required":false,"pdf_field":""},{"help":"Travel identification number","type":"text","label":"Unique Identification of Travel (Ex. PNR, Flight No, etc.)","options":[],"required":false,"pdf_field":""},{"help":"Mode of travel","type":"text","label":"Mode of Travel","options":[],"required":false,"pdf_field":""},{"help":"Scheduled travel times","type":"text","label":"Scheduled Departure & Arrival","options":[],"required":false,"pdf_field":""},{"help":"Actual travel times","type":"text","label":"Actual Departure & Arrival","options":[],"required":false,"pdf_field":""},{"help":"Hospital details where treatment was taken","type":"text","label":"Name and Address of the Hospital","options":[],"required":false,"pdf_field":""},{"help":"Type of room occupied during hospitalization","type":"text","label":"Room Category occupied","options":[],"required":false,"pdf_field":""},{"help":"Reason for hospitalization","type":"text","label":"Hospitalization due to","options":[],"required":false,"pdf_field":""},{"help":"Relevant date in DD/MM/YYYY format","type":"date","label":"Date of injury/Date disease first detected/Date of Delivery","options":[],"required":false,"pdf_field":""},{"help":"Date of hospital admission","type":"date","label":"Date of Admission","options":[],"required":false,"pdf_field":""},{"help":"Time of admission in HH:MM hrs","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"Date of hospital discharge","type":"date","label":"Date of Discharge","options":[],"required":false,"pdf_field":""},{"help":"Time of discharge in HH:MM hrs","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"Specify system of medicine","type":"text","label":"System of Medicine (Allopathic/AYUSH)","options":["Allopathic","AYUSH"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Was there any witness to the Accident (Yes/No)","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Section VIII – Documents Required for Submission of Claim","fields":[{"help":"Attach all listed documents as applicable","type":"attachment","label":"Documents Required","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Section IX – Details of Bank Account for Claim Payment","fields":[{"help":"Name of bank for claim payment","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Branch of bank","type":"text","label":"Bank Branch","options":[],"required":true,"pdf_field":""},{"help":"Account number for claim payment","type":"text","label":"Bank Account Number","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"MICR code of bank branch","type":"text","label":"MICR Code","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person or claimant"},{"title":"Section X – Declaration by Claimant","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant"},{"title":"Section XI – Direct Fund Transfer / EFT Mandate Form","fields":[{"help":"Select Yes or No","type":"choice","label":"Would you like to opt for Electronic Fund Transfer as mode of payment?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name as per bank records","type":"text","label":"Payee Name (as per bank records)","options":[],"required":false,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Payee Account No.","options":[],"required":false,"pdf_field":""},{"help":"Type of bank account","type":"text","label":"Type of Account","options":[],"required":false,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name","options":[],"required":false,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address of the Bank","options":[],"required":false,"pdf_field":""},{"help":"IFSC code","type":"text","label":"IFSC Code of the Bank","options":[],"required":false,"pdf_field":""},{"help":"MICR code","type":"text","label":"MICR Code No. of the Bank","options":[],"required":false,"pdf_field":""},{"help":"PAN number","type":"text","label":"Permanent Account Number (PAN) of Payee","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Claimant","options":[],"required":false,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant"},{"title":"Claim Form Part – B: To be completed by the Hospital","fields":[{"help":"Hospital name","type":"text","label":"Name of the Hospital","options":[],"required":true,"pdf_field":""},{"help":"Hospital identification number","type":"text","label":"Hospital ID","options":[],"required":false,"pdf_field":""},{"help":"Type of hospital","type":"text","label":"Type of Hospital","options":[],"required":false,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of the treating doctor","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification","options":[],"required":false,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration No. with State Code","options":[],"required":false,"pdf_field":""},{"help":"Doctor's mobile number","type":"phone","label":"Telephone Number: Mobile","options":[],"required":false,"pdf_field":""},{"help":"Patient's name","type":"text","label":"Name of the Patient","options":[],"required":true,"pdf_field":""},{"help":"Inpatient registration number","type":"text","label":"IP Registration No.","options":[],"required":false,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender (M / F)","options":["M","F"],"required":true,"pdf_field":""},{"help":"Age in years and months","type":"text","label":"Age (YY/MM)","options":[],"required":true,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Admission date","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Admission time HH:MM hrs","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"Discharge date","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Discharge time HH:MM hrs","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"Select type of admission","type":"choice","label":"Type of admission","options":["Emergency","Planned","Day Care","Maternity"],"required":true,"pdf_field":""},{"help":"Date of delivery if maternity","type":"date","label":"If Maternity: Date of Delivery","options":[],"required":false,"pdf_field":""},{"help":"Gravida status if maternity","type":"text","label":"Gravida Status","options":[],"required":false,"pdf_field":""},{"help":"Select discharge status","type":"choice","label":"Status at time of discharge","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":true,"pdf_field":""},{"help":"Total amount claimed","type":"amount","label":"Total Claimed Amount","options":[],"required":true,"pdf_field":""},{"help":"Details of procedures performed","type":"text","label":"Details of Procedure","options":[],"required":false,"pdf_field":""},{"help":"Specify if applicable","type":"text","label":"Present ailment is a complication of PED","options":[],"required":false,"pdf_field":""},{"help":"Details of complication","type":"text","label":"If yes, specify details","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Pre-authorization obtained (Yes/No)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Pre-authorization number if obtained","type":"text","label":"Pre-authorization No.","options":[],"required":false,"pdf_field":""},{"help":"Reason if no authorization","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":""},{"help":"Reason for hospitalization","type":"text","label":"Hospitalization due to","options":[],"required":false,"pdf_field":""},{"help":"Specify cause if injury","type":"text","label":"If injury give cause (Y/N): Self Inflicted, Road Traffic Accident, Substance Abuse/Alcohol","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"If Medico Legal (Y/N)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Reported to Police (Y/N)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"MLC Report and FIR attached (Y/N)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Reason for not reporting","type":"text","label":"If not reported to Police, give reason","options":[],"required":false,"pdf_field":""},{"help":"City of hospital","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"State of hospital","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"PIN code of hospital","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Hospital mobile number","type":"phone","label":"Telephone Number: Mobile","options":[],"required":false,"pdf_field":""},{"help":"Hospital email","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""},{"help":"Hospital DOB if applicable","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Hospital registration number","type":"text","label":"Registration No. with State Code","options":[],"required":false,"pdf_field":""},{"help":"Hospital PAN number","type":"text","label":"Hospital PAN","options":[],"required":false,"pdf_field":""},{"help":"Number of inpatient beds","type":"number","label":"No. of in-patient beds","options":[],"required":false,"pdf_field":""},{"help":"Specify facilities available","type":"text","label":"Facilities available in the Hospital: OT (Yes/No), ICU (Yes/No), Others","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Date of declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Signature and seal","type":"signature","label":"Signature and Seal of the Hospital Authority","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Group Health Insurance Policy claims","attachments":["Copies of valid KYC documents of the Nominee/claimant (such as Passport/ PAN Card/Aadhar number etc)","Legal heir certificate (if applicable)","Copy of FIR/MLC","Hospital main bill, break-up bill, bill payment receipt, discharge summary, operation theatre notes, Doctor’s request for investigation","Death Certificate attested by issuing/ appropriate authority","Leave certificate from the employer (Hospitalization claims)","Name and address of the attending Medical Practitioner","Medical reports, case histories, investigation reports, treatment papers as applicable","Discharge summary/certificate","Certification of disability along with percentage of disability/ Photograph of the injured with reflecting disablement (if applicable)","Travel Tickets","Proof of Loss/ Inconvenience provided by the travel organizer/ service provider","Ownership proof/ invoice of lost item","Any other information relevant to the Injury/Hospitalization/illness","Additional documents depending on the nature of the claim will be requested as and when required (if applicable)","Original blank cancelled cheque signed by the Payee (for EFT)","PAN CARD copy of Payee (for EFT)","Hospital main bill, break-up bill, bill payment receipt, discharge summary, operation theatre notes, Doctor’s request for investigation (hospital section)","Medical reports, case histories, investigation reports, treatment papers as applicable (hospital section)","Discharge summary/certificate (hospital section)","ECG (hospital section)","Pharmacy Bills (hospital section)","Copy of FIR/MLC (hospital section)","Any other information relevant to the Injury/Hospitalization (hospital section)","Additional documents depending on the nature of the claim will be requested as and when required (hospital section)"],"declarations":["The information furnished in this claim form is true, complete and accurate 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 benefits shall be forfeited.","Consent and authorization is given to Acko General Insurance Ltd to seek necessary medical information/documents from any hospital, medical practitioner, travel organiser or service provider.","The information furnished by the hospital is true, complete and accurate to the best of their knowledge and belief.","If the hospital makes any false or untrue statement or conceals material facts, their right to claim shall be forfeited.","Submission of documents or bank details or any other information does not imply admission of liability by the company.","Terms and conditions apply for payment through RTGS/NEFT as described in the mandate form."],"dropped_labels":17},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Claims Department, ACKO LIFE INSURANCE LIMITED., 36/5, Hustle Hub One East, Somasandrapalya, 27th Main Road, Sector 2, HSR Layout, Somasandrapalya HSR 2nd Sector Bus Stop, Bengaluru, Bengaluru Urban, Karnataka, 560102","label":"Claims postal address","level":null,"hours":null,"applies_to":"life","source_url":"https://acko-cms.ackoassets.com/2_Acko_Life_Group_Term_Protect_Micro_Insurance_Master_Policy_Document_ca9093f4de.pdf","quote":"at claims.life@acko.com or by sending the documents to the address mentioned below or any other office of the Company:\nClaims Department, ACKO LIFE INSURANCE LIMITED., 36/5, Hustle Hub One East, Somasandrapalya, 27th Main Road, Sector 2, HSR Layout, Somasandrapalya HSR 2nd Sector Bus Stop, Bengaluru, Bengaluru Urban, Karnataka, 560102\n\nAny person claiming the Death Benefit under this Policy can download the claim request documents from Our website www.","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-210-1992","label":"Claims phone number","level":null,"hours":"9:00 AM – 8:00 PM","applies_to":"life","source_url":"https://www.acko.com/life/claims/","quote":"t us\nSupport\nRenewals\nNew to ACKO?\nRenew life insurance\nExisting ACKO Customer\nLogin and renew policy\nClaims\nCall us at\n1800-210-1992\nEmail us at\n[email protected]\nLogin\nACKO Life Home\n/\nACKO Life Insurance Claims Process\nGroup Claims Process\nClaims Pro","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/acko-life-insurance/32-acko-group-health-insurance-policy-claim-form"}