{"id":2122,"title":"TRAVEL PRIME PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/travel-insurance/travel-prime-family/travel-prime-family-pf.pdf","sha256":"e4f43f37e60b0493925fc9a091ac20c4fa074906f7805b7fa86b1829c5779ccf","pages":9,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or families proposing to purchase Travel Prime insurance plans from Bajaj General Insurance. The proposer fills it to provide personal, travel, health, and plan details for underwriting and policy issuance.","notes":["Please answer all questions in BLOCK letters.","Attach a separate sheet if space is insufficient.","Policy liability starts only after proposal acceptance and premium payment.","Nominee for self must be one of the specified relations; specify if 'Others'.","Use original documents and provide accurate medical history.","Keep policy contact and bank details updated for faster service.","Read declaration carefully before signing."],"title":"TRAVEL PRIME PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter full name in BLOCK letters","type":"text","label":"Name of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter contact phone number","type":"phone","label":"Phone No:","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-mail :","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth in DD-MM-YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Enter passport number","type":"text","label":"Passport No :","options":[],"required":true,"pdf_field":""},{"help":"Enter current occupation","type":"text","label":"Occupation :","options":[],"required":true,"pdf_field":""},{"help":"Enter departure date in DD-MM-YYYY format","type":"date","label":"Departure Date","options":[],"required":true,"pdf_field":""},{"help":"Enter arrival date in DD-MM-YYYY format","type":"date","label":"Arrival Date","options":[],"required":true,"pdf_field":""},{"help":"Select the geographical coverage area","type":"choice","label":"Geographical Location","options":["Worldwide Including USA/Canada","Worldwide Excluding USA/Canada","Asia Excluding Japan"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Constitution Details","fields":[{"help":"","type":"yes-no","label":"Partnership Firm","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Limited Liability/Partnership Firm","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide DARPAN registration details if applicable","type":"yes-no","label":"NGO/NPO- Provide DARPAN Portal Registration, if applicable","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Company","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Trust","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Society","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Section 8 Company","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Proprietorship Firm","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify other constitution if applicable","type":"text","label":"Others (Please specify)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Plan Selection","fields":[{"help":"Select the insurance plan you want to apply for","type":"choice","label":"Choose Plans","options":["Travel Prime Family Plan - Standard: 50000 USD","Travel Prime Family Plan - Silver: 100000 USD","Travel Prime Student Plans - Standard: 50000 USD","Travel Prime Student Plans - Platinum: 300000 USD","Travel Prime Student Plans - Maximum: 1000000 USD","Travel Prime Student Plans - Silver: 100000 USD","Travel Prime Student Plans - Super Gold: 500000 USD","Travel Prime Student Plans - Gold: 200000 USD","Travel Prime Student Plans - Super Platinum: 750000 USD","Travel Prime Holiday Plans & Travel Prime Asia Plans - Asia Flair: 15000 USD","Travel Prime Holiday Plans & Travel Prime Asia Plans - Asia Supreme: 25000 USD","Travel Prime Individual Plans and Travel Prime Holiday Plans - Silver: 50000 USD","Travel Prime Individual Plans and Travel Prime Holiday Plans - Gold: 200000 USD","Travel Prime Individual Plans and Travel Prime Holiday Plans - Super Platinum: 750000 USD","Travel Prime Individual Plans and Travel Prime Holiday Plans - Platinum: 500000 USD","Travel Prime Individual Plans and Travel Prime Holiday Plans - Maximum: 1000000 USD","Travel Prime Age Plans - Silver: 50000 USD","Travel Prime Age Plans - Super Platinum: 750000 USD","Travel Prime Age Plans - Gold: 200000 USD","Travel Prime Age Plans - Platinum: 500000 USD","Travel Prime Age Plans - Maximum: 1000000 USD","Travel Prime Super Age Plan: 50000 USD","Travel Prime Corporate Plans - Corporate Lite: 250000 USD","Travel Prime Corporate Plans - Corporate Maximum: 1000000 USD","Travel Prime Corporate Plans - Corporate Age Plus: 200000 USD","Travel Prime Corporate Plans - Corporate Plus: 500000 USD","Travel Prime Corporate Plans - Corporate Age Lite: 50000 USD"],"required":true,"pdf_field":""},{"help":"Select age group if applicable","type":"choice","label":"Age","options":["71-75 Yrs","76-80 Yrs","81-85 Yrs","86-90 Yrs","More than 90 Yrs"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"With Pre Policy Health Check Up","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Without Pre Policy Health Check Up","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Journey within 30 Days","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Journey after 30 Days","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details of Persons to be Insured","fields":[{"help":"Fill details for up to 4 insured persons; nominee must be one of specified relations","type":"table","label":"Family Members (Sr. No, Name, Date of Birth, Gender, Passport No., Nominee)","options":[],"required":true,"pdf_field":""},{"help":"Specify nominee relation or other if applicable","type":"text","label":"Nominee for self has to be one of the below mentioned relations. If Nominee is \"Others\" please specify","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Medical History","fields":[{"help":"Answer for each insured person","type":"yes-no","label":"During the last 4yrs and before 4yrs, have any of the proposed insured consulted any physician for treatment or medical investigation or surgical operation, Accident or been hospitalized for any disorder?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Have any of the proposed insured’s ever been diagnosed with or advised to seek treatment for any one or more from the following: heart disease, Diabetes/ raised blood sugar, High blood pressure/ Hypertension, Circulatory disease?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Paralysis, cancer, Disease of kidney, Liver, Stomach, Intestine, brain, Lung or joint disorder, mental illness, Congenital/ Birth defect ,Physical deformity, or HIV/AIDS","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Any other illness, impairment, disability or surgery not mentioned above?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured person","type":"yes-no","label":"Disorders of eye, ear, nose or throat, Gland disorder such as thyroid, Blood disorder or disorder of reproductive or urinary system","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Have any of the proposed insured’s Parents, brothers or sisters had heart disorders, cancer, Diabetes, neurological or mental disorder, hereditary or chronic disorder?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Is any of the proposed insured currently taking any medication/ treatment for any disease or disorder?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Is any of the proposed insured is currently pregnant","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Have any of the proposed insured proposal or application for reinstatement of life, health and accident insurance ever been declined, postponed, withdrawn or accepted with modified terms by any insurance company?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Does any person proposed to be insured smoke or consume tobacco, alcohol or any other form of Tobacco?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Optional Covers under Travel Prime Student Plan","fields":[{"help":"Select if opting for this cover; sum insured USD 1000","type":"yes-no","label":"Cancer Screening and Mammography Cover (Yes/No)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select sum insured option if opting: USD 1000, 2000, 2500, or 3000","type":"yes-no","label":"HIV(Human Immunodeficiency Virus) and AIDS (Acquired Immunodeficiency Syndrome) (Yes/No)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Sum insured as per the Base Travel Prime Student Plan","type":"yes-no","label":"Pre Existing Illness Coverage (Yes/No)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Sum insured as per the Base Travel Prime Student Plan","type":"yes-no","label":"Maternity and Baby Cover from Day One Coverage (Yes/No)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Sum insured as per the Base Travel Prime Student Plan","type":"yes-no","label":"Mental Illness and Alcohol Related Disorder Cover (Yes/No)","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Information","fields":[{"help":"Provide details if any medical history or conditions not covered above","type":"table","label":"Additional Information (Sr. No, Name of the proposed Insured, Illness details with symptoms, Treatment details with treating Doctor details, Outcome of treatment)","options":[],"required":false,"pdf_field":""},{"help":"Enter full name of student","type":"text","label":"Additional information to be completed by the student (Only for Travel Prime Student plan): Name Of the Student","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth of student","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Enter school name","type":"text","label":"Name of the School Overseas","options":[],"required":false,"pdf_field":""},{"help":"Enter full address and phone number","type":"text","label":"Detailed Address of the School/Telephone no","options":[],"required":false,"pdf_field":""},{"help":"Enter course name","type":"text","label":"Course Opted for","options":[],"required":false,"pdf_field":""},{"help":"Enter course duration","type":"text","label":"Duration of the Course","options":[],"required":false,"pdf_field":""},{"help":"Enter number of semesters","type":"number","label":"Number of Semesters","options":[],"required":false,"pdf_field":""},{"help":"Enter tuition fees amount per semester","type":"amount","label":"Tuition Fees Per Semester","options":[],"required":false,"pdf_field":""},{"help":"Specify source of tuition financing","type":"text","label":"Tuitions financed by (Self, parents, borrowing from bank or FI's), please give details","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you undergone medical examination/fitness test?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide any additional relevant information","type":"text","label":"Would like to state any thing that is not asked which you may want the insurer to know?","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Information for Travel Prime Holiday","fields":[{"help":"Enter total number of passengers","type":"number","label":"Number of Passengers","options":[],"required":false,"pdf_field":""},{"help":"Enter total number of travel days","type":"number","label":"Number of Travel Days","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Provide payment mode and cheque details if applicable","type":"text","label":"Payment Details (Cash / Cheque, Amount, Bank/Name, Cheque No, Cheque Dt, Branch)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration & Signature","fields":[{"help":"Print your name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date (DD/MM/YY)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations – Physical Proposal Form","fields":[{"help":"Politically Exposed Persons declaration","type":"yes-no","label":"Are you or any of the proposal applicants a PEP* or a close relative of PEP*? If yes, please share the details","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Travel Prime Family Plan, Travel Prime Student Plans, Travel Prime Holiday Plans, Travel Prime Asia Plans, Travel Prime Individual Plans, Travel Prime Age Plans, Travel Prime Corporate Plans","attachments":["Separate sheet if insufficient space for information","Annexure stating details of passengers for Travel Prime Holiday Plan"],"declarations":["The information provided is true and complete to the best of the proposer's knowledge.","The policy will come into force only after full receipt of premium.","Notify in writing any change in occupation or health after proposal submission but before risk acceptance.","Consent to company seeking medical information from doctors, hospitals, employers, and other insurers for underwriting and claims.","Consent to company sharing proposal and medical records with governmental or regulatory authorities.","Agreement to the company's Privacy Policy terms and conditions.","Declaration regarding PEP status and consent for KYC verification.","Declaration that premiums are paid from legally acquired income sources.","Consent to share personal data with group companies for insurance and related services."],"dropped_labels":4},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"careforyou@bajajgeneral.com","label":"Customer Service Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/forms/form-online-grievance.html","quote":"in a new tab\nBajaj General Insurance Limited\nTollfree: For sales :\n1800-209-0144\nFor service :\n1800-209-5858\nEmail id:\ncareforyou@bajajgeneral.com\nFor senior citizens:\nseniorcitizen@bajajgeneral.com\nFor senior citizens:\n1800-209-5858\nFax no:\n020-30512246\nRegistered","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-209-5858","label":"Service Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/forms/form-online-grievance.html","quote":"Careers\nBecome\n                                An Agent\nAwards\nUpdate KYC\nMY ABHA\nBuy Policy:\n1800-209-0144\n| Service:\n1800-209-5858\nService Chat:\n+91 75074 25858\nInsure\nHealth Insurance\nIndividual Health Insurance\nFamily Health Insurance\nInternational","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-209-0144","label":"Sales Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/forms/form-online-grievance.html","quote":"nsurance\nSupport\nAbout Us\nCareers\nBecome\n                                An Agent\nAwards\nUpdate KYC\nMY ABHA\nBuy Policy:\n1800-209-0144\n| Service:\n1800-209-5858\nService Chat:\n+91 75074 25858\nInsure\nHealth Insurance\nIndividual Health Insurance\nFamily Healt","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-209-5858","label":"Customer Service Toll Free Number","level":1,"hours":null,"applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/about-us/customer-service.html","quote":"ted servicing team to help you meet your service needs.\nCustomer Service - We're Here to Help\nDial our Toll Free Number\n1800-209-5858\nEmail us on\ncareforyou@bajajgeneral.com\nToll free No. Intermediary\n1800-209-7073\nBOING BOT\nConnect with us on BOING Cha","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"ggro@bajajgeneral.com","label":"Grievance Redressal Officer Email Mr. Jerome Vincent","level":2,"hours":null,"applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/about-us/customer-service.html","quote":"fied with the response given to you by our team, you may write to our Grievance Redressal Officer Mr. Jerome Vincent at\nggro@bajajgeneral.com\nLevel 3\nHead Customer Service\nif you are still not satisfied with the solutions provided, or have some feedback for us,","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-209-7073","label":"Toll free No. Intermediary","level":null,"hours":null,"applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/about-us/customer-service.html","quote":"Here to Help\nDial our Toll Free Number\n1800-209-5858\nEmail us on\ncareforyou@bajajgeneral.com\nToll free No. Intermediary\n1800-209-7073\nBOING BOT\nConnect with us on BOING Chatbot\nConnect with us on WhatsApp +91 7507425858\nFor Support\nBajaj General App\nPle","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"whatsapp","value":"+91 7507425858","label":"BOING WhatsApp Chatbot","level":null,"hours":"24x7","applies_to":"all","source_url":"https://www.bajajgeneralinsurance.com/about-us/customer-service.html","quote":"ral.com\nToll free No. Intermediary\n1800-209-7073\nBOING BOT\nConnect with us on BOING Chatbot\nConnect with us on WhatsApp +91 7507425858\nFor Support\nBajaj General App\nPlease scan and download\nMissed Call Facility\nMissed Call - 80809 45060 Short code - SMS","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/bajaj-general-insurance/2122-travel-prime-proposal-form"}