{"id":2140,"title":"PROPOSAL FORM Nimagagi- Karnataka","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/aapke-liye/nimagagi-karnataka/Nimagagi-Karnataka_Digital_PF.pdf","sha256":"137364b40b90c686daf8f107e0c55df5ec3d079b24120b56945e4c3e47b83f78","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a health insurance proposal form to be filled by the proposer (policyholder) to apply for a new or renewal health insurance policy with Bajaj General Insurance Limited.","notes":["Please answer all questions in BLOCK letters.","Liability of the company starts only after acceptance of proposal and payment of premium.","Provide all information fully and accurately.","Use original documents and provide additional information relevant to risk.","Nominee for primary insured must be one of the specified relations or specify reason if others.","Once optional covers are opted, they cannot be opted out at subsequent renewals.","Submission of proposal or payment does not oblige the company to issue a policy.","No rebate of commission or premium is allowed as per Insurance Act 1938 Section 41."],"title":"PROPOSAL FORM Nimagagi- Karnataka","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter your full name in block letters","type":"text","label":"Full Name : Title First Name Middle Name Surname","options":[],"required":true,"pdf_field":"Title, First Name, Middle Name, Surname"},{"help":"If existing policy, enter policy number","type":"text","label":"The Policy No.","options":[],"required":false,"pdf_field":"Policy No OG"},{"help":"Enter your existing customer PID number if any","type":"text","label":"Existing Customer (PID) No.","options":[],"required":false,"pdf_field":"PID NO"},{"help":"","type":"checkbox","label":"I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy","options":["Yes"],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":"Gender.0"},{"help":"Enter your date of birth (DD/MM/YYYY)","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":"DOB FROM"},{"help":"Enter your PAN number","type":"text","label":"Pan No.","options":[],"required":false,"pdf_field":"Pan No"},{"help":"Tick if you consent to credit score discount","type":"checkbox","label":"Do you wish to avail credit score discount if yes please provide below consent CIBIL Discount.","options":["Yes"],"required":false,"pdf_field":""},{"help":"Enter last 4 digits of Aadhaar number","type":"text","label":"UID/Aadhaar No. Enter last 4 digits only","options":[],"required":false,"pdf_field":"Aadhaar No"},{"help":"Select your marital status","type":"choice","label":"Marital Status","options":["Married","Single","Divorced","Widowed"],"required":false,"pdf_field":""},{"help":"Enter number of sons and daughters","type":"number","label":"No. of children: Sons Daughters","options":[],"required":false,"pdf_field":""},{"help":"Select your occupation or specify if Other","type":"choice","label":"Occupation","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":false,"pdf_field":"Occupation.0"},{"help":"Select Yes or No","type":"yes-no","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide ABHA number if applicable","type":"text","label":"If Yes please share your Ayushmaan Bharat Health Account Number (ABHA) No. in below table","options":[],"required":false,"pdf_field":"ABHA Number101.0"}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Enter your communication address and contact details","type":"text","label":"Communication Address (all communications will be sent to below): House No., House Name, Landmark/Locality, Road/Area Name, City/District, State, Pin Code, Telephone, Mobile, Email","options":[],"required":true,"pdf_field":"House No1, House Name_2, LandMark, Road Name, CityDistrict_2, State_2, Pin Code1, TelephoneNo1, MobileNo1, Email_2"}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"Select your highest educational qualification","type":"choice","label":"Educational Qualification","options":["Matriculate","Under Graduate","Graduate","Post Graduate","Professionally Qualified"],"required":false,"pdf_field":""},{"help":"Enter your monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":"Monthly Income"},{"help":"Enter your nationality","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":"Nationality"},{"help":"Select the policy term","type":"choice","label":"Policy Term","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Select policy type","type":"choice","label":"Policy type","options":["Individual","Floater"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Specify relationship and reason if nominee is 'Others'","type":"text","label":"If Nominee is Others please specify the relationship and reason","options":[],"required":false,"pdf_field":"If Nominee is Others please specify the relationship and reason"}],"filled_by":"proposer"},{"title":"Plan and Sum Insured Details","fields":[{"help":"Enter sum insured details for each member","type":"table","label":"Member Name, Sum Insured (Individual), Sum Insured (Floater)","options":[],"required":true,"pdf_field":"Member NameRow1, Sum Insured IndividualRow1, Sum Insured FloaterRow1 and similar for other members"}],"filled_by":"proposer"},{"title":"Loyalty Discount and Other Insurance Details","fields":[{"help":"Enter details of other insurances for loyalty discount","type":"table","label":"Do you have Motor, Health/ Personal Accident, Home, Cyber and Pet Insurance with premium more than INR 2500? Provide Policy number, Policy period, LOB for up to 10 members","options":[],"required":false,"pdf_field":"Policy numberMember 1, Policy periodMember 1, LOBMember 1 and similar for other members"},{"help":"Select if opting for Health Prime Rider","type":"checkbox","label":"Health Prime Rider","options":["Yes","No","Individual Option 3","Floater Option 1"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Status","fields":[{"help":"Answer for each insured member and provide details if Yes","type":"yes-no","label":"Has any proposal for life, critical illness or health insurance ever been postponed, declined or accepted on special terms? If yes, give details","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Details and Payment","fields":[{"help":"Select payment mode","type":"choice","label":"Payment Mode: Full Payment / Instalment Payment (Monthly, Quarterly, Half, Annual)","options":["Full Payment","Instalment Payment Monthly","Instalment Payment Quarterly","Instalment Payment Half","Instalment Payment Annual"],"required":true,"pdf_field":""},{"help":"Provide payment details","type":"text","label":"Payment Details: Cash, Cheque, DD, Credit Card, Debit Card, UPI; Amount, Transaction No., Transaction Date, Bank Name, Branch","options":[],"required":true,"pdf_field":""},{"help":"Select who gave the check","type":"choice","label":"Check- Given By: Spouse, Father, Mother, Son/Daughter, Employer/Employee, Financier","options":["Spouse","Father","Mother","Son/Daughter","Employer/Employee","Financier"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"BIMA ASBA Declaration and Bank Details","fields":[{"help":"Provide bank details for policy servicing","type":"text","label":"Bank Details: Name as per Bank Account, Name of the Bank, IFSC Code, Bank Account No, Account Type, Mobile No, Email Address","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Signatures","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Intermediary to sign","type":"signature","label":"Signature of Intermediary","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and intermediary"}],"deadlines":[],"applies_to":"Health insurance proposals under Nimagagi-Karnataka scheme","attachments":[],"declarations":["The information provided is true and complete to the best of my knowledge.","I will notify any change in occupation or health after submission and before acceptance.","I consent to the company seeking medical and insurance information for underwriting and claims.","I consent to sharing my proposal and medical records with reinsurers and regulatory authorities.","I consent to sharing personal information with group companies for marketing (optional).","I consent to KYC verification through CERSAI or NSDL portals.","I declare that premiums are paid from legally acquired income.","I declare if I or any applicant is a Politically Exposed Person (PEP) or close relative."],"dropped_labels":25},"pdf_fields":[{"name":"Scrutiny NoRow1","page":1,"type":"text","label":"Scrutiny No._Row_1"},{"name":"Receipt NoRow1","page":1,"type":"text","label":"Receipt No._Row_1"},{"name":"Policy NoRow1","page":1,"type":"text","label":"Policy No._Row_1"},{"name":"Loan Account NumberRow1","page":1,"type":"text","label":"Loan Account Number_Row_1"},{"name":"EmpLG CodeRow1","page":1,"type":"text","label":"Emp/LG Code_Row_1"},{"name":"IMD CodeRow1","page":1,"type":"text","label":"IMD Code_Row_1"},{"name":"Sub IMD CodeRow1","page":1,"type":"text","label":"Sub IMD Code_Row_1"},{"name":"IMD NameRow1","page":1,"type":"text","label":"IMD Name_Row_1"},{"name":"Mobile NoRow1","page":1,"type":"text","label":"Mobile No_Row_1"},{"name":"Title","page":1,"type":"text","label":"First Name"},{"name":"First Name","page":1,"type":"text","label":"First Name"},{"name":"Middle Name","page":1,"type":"text","label":"First Name"},{"name":"Surname","page":1,"type":"text","label":"First Name"},{"name":"Policy No OG","page":1,"type":"text","label":"a. 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(cms)_(dd/mm"},{"name":"DOB1.0","page":2,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.0","page":2,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.0","page":2,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.0","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0","page":2,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Occupation.0","page":2,"type":"text","label":"Occupation_(dd/mm"},{"name":"Relation1.0","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Nationality101.0","page":2,"type":"text","label":"Nationality"},{"name":"ABHA Number101.0","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M2","page":2,"type":"text","label":"Ht. 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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 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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. 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