{"id":2130,"title":"COMPULSORY PERSONAL ACCIDENT (OWNER – DRIVER) UNDER MOTOR INSURANCE POLICIES Proposal Form","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/motor-insurance/motor-pf/Compulsory-Personal-Accident-PF.pdf","sha256":"d7a667c950199c2c02e9d03901a3fa1847d88860595d8b0fdf9c5d14d3ed38f5","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for compulsory personal accident cover for the owner-driver under motor insurance policies. It is filled by the insured owner-driver applying for the cover.","notes":["Please answer all questions in BLOCK letters.","The liability of the company does not commence until this proposal has been accepted and premium received.","Provide all information fully and accurately including any additional information relevant to risk.","Use the usual terms and conditions prescribed by the Company.","Section 41 of Insurance Act, 1938 prohibits rebates as inducements and prescribes penalties for violations."],"title":"COMPULSORY PERSONAL ACCIDENT (OWNER – DRIVER) UNDER MOTOR INSURANCE POLICIES Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposed Coverage and Proposer Details","fields":[{"help":"Enter your full name in BLOCK letters","type":"text","label":"Name of Insured (Owner Driver)","options":[],"required":true,"pdf_field":""},{"help":"Enter your full postal address including State and Pin code","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter your mobile phone number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":""},{"help":"Enter your email address","type":"email","label":"Email Id","options":[],"required":false,"pdf_field":""},{"help":"Enter your occupation","type":"text","label":"Occupation","options":[],"required":true,"pdf_field":""},{"help":"Enter the start and end dates of coverage","type":"date","label":"Coverage Period From ____/____/______ To ____/_____/_________","options":[],"required":true,"pdf_field":""},{"help":"Enter the nominee's name and relationship to you","type":"text","label":"Nominee Name and Relationship Details","options":[],"required":true,"pdf_field":""},{"help":"Select Yes if you have a valid driving license, else No","type":"choice","label":"Do you have valid Driving License? Yes / No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes if you have opted for any add-on cover, else No","type":"choice","label":"Add on Cover Opted (If any) Yes / No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details of the add-on cover if applicable","type":"text","label":"If Yes, please provide details of the Add on Cover","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer (owner-driver)"},{"title":"Declaration","fields":[{"help":"Enter the place where you are signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter the date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Print your name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Tick this box if you agree that the terms and conditions have been explained in your vernacular language","type":"checkbox","label":"The salient features of the policy, terms and conditions of this proposal have been explained to me/us invernacular language, and I/We agree to the same. (Please tick in case same is agreed)","options":["Tick if agreed"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Constitution Details","fields":[{"help":"Provide DARPAN portal registration details if applicable","type":"text","label":"DARPAN DETAILS","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations – Physical Proposal Form","fields":[{"help":"Select Yes if you or any applicant is a Politically Exposed Person or close relative, else No","type":"choice","label":"Are you or any of the proposal applicants a PEP* or a close relative of PEP*? Yes / No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if you answered Yes above","type":"text","label":"If yes, please share the details","options":[],"required":false,"pdf_field":""},{"help":"Consent for KYC verification","type":"choice","label":"I/we hereby give my/our consent to the Company to verify and obtain my/our identity/address proof through CERSAI records or National Securities Depository Limited Portal for the purpose of undertaking KYC verification. Yes / No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Confirm that premiums are paid from legal sources","type":"choice","label":"I/we hereby declare and confirm that the premium has been paid out of legally acquired sources of income and the subsequent premiums if any, will continue to be paid out of legally declared and assessed source of income. Yes / No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Consent to share personal information with group companies","type":"choice","label":"I/We hereby give voluntary consent to BGIL/Company to share my/our personal information and data provided in this proposal form with its group companies or any other person in connection with the Insurance Policy or otherwise, including for providing products and services of group companies that may be of interest to me/us, to be used in accordance with their respective privacy policies and subject to appropriate measures being in place to safeguard my/our personal information. Yes / No","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Compulsory Personal Accident Cover under Motor Insurance Policies","attachments":[],"declarations":["The insurance contract and policy is subject to the declarations, warranties, statements and particulars given in this proposal form.","Statements and particulars given in this proposal form shall be the basis of the insurance contract.","The Company shall have no liability if any statements or particulars are incorrect, untrue, suppressed, misleading or false on any material matter.","The proposer agrees to accept the usual terms and conditions and form of the policy prescribed and issued by the Company.","The proposer agrees to receive a one-page policy document without enclosing the terms and conditions, which will be available on the Company's website.","The salient features of the policy, terms and conditions have been explained in vernacular language and agreed to by the proposer.","Premiums have been and will be paid from legally acquired sources of income.","Consent is given for KYC verification through CERSAI or NSDL portals.","Voluntary consent is given to share personal information with group companies for products and services."],"dropped_labels":1},"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/2130-compulsory-personal-accident-owner-driver-under-motor-insurance-policies-proposa"}