{"id":2141,"title":"PROPOSAL FORM Apananka Pain- Odisha","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/aapke-liye/apananka-pain-odisha/Apananka_Pain-Odisha_Proposal_Form.pdf","sha256":"6fa722452adbad801aafb16a8caaf5ab369253be0266c5cbc2289fd753166d3e","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 the Apananka Pain- Odisha health insurance policy.","notes":["Please answer all questions in BLOCK letters.","Liability of the company starts only after proposal acceptance and premium payment.","Provide all information fully and accurately including any additional relevant information.","Use original documents and provide correct details to avoid rejection.","Nominee for primary insured must be one of the specified relations or specify if others.","Once optional covers are opted, cannot opt out at subsequent renewals except accidental death cover.","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 Apananka Pain- Odisha","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":""},{"help":"If existing policy, enter policy number","type":"text","label":"The Policy No.","options":[],"required":false,"pdf_field":""},{"help":"If existing customer, enter PID number","type":"text","label":"Existing Customer (PID) No.","options":[],"required":false,"pdf_field":""},{"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":"","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"Pan No.","options":[],"required":false,"pdf_field":""},{"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":""},{"help":"","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":"If Other, specify occupation","type":"choice","label":"Occupation","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":false,"pdf_field":""},{"help":"","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":"Enter ABHA number if applicable","type":"text","label":"If Yes please share your Ayushmaan Bharat Health Account Number (ABHA) No.","options":[],"required":false,"pdf_field":""},{"help":"Enter full permanent address","type":"text","label":"Address a. Permanent /Residential Address","options":[],"required":true,"pdf_field":""},{"help":"Enter full communication address","type":"text","label":"Address b. Communication Address (all communications will be sent to below)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"","type":"choice","label":"Educational Qualification","options":["Matriculate","Under Graduate","Graduate","Post Graduate","Professionally Qualified"],"required":false,"pdf_field":""},{"help":"Enter monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Policy Term","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy type","options":["Individual","Floater"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee details; if nominee is minor, provide appointee details","type":"table","label":"Name, DOB (dd/mm/yyyy), Age, Relation","options":[],"required":true,"pdf_field":""},{"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":""}],"filled_by":"proposer"},{"title":"Plan and Sum Insured Details","fields":[{"help":"Select applicable optional covers for each insured member","type":"table","label":"Member Name, Sum Insured (Individual), Sum Insured (Floater), Optional Covers (Sum Insured Reinstatement, Super Cumulative Bonus, Procedure wise/ Disease wise sub-limit, Cashless Discount, Voluntary Copayment or Aggregate Deductible, Accidental Death Cover, Loyalty Discount)","options":["Sum Insured Reinstatement: Once, Unlimited","Super Cumulative Bonus: 25% of SI max 100%, 25% of SI max 200%, 50% of SI max 100%","Voluntary Copayment: 5%, 10%, 15%, 20%","Voluntary Aggregate Deductible: 10,000, 20,000, 30,000, 40,000, 50,000, 1,00,000, 2,00,000, 3,00,000","Accidental Death Cover: Yes, No"],"required":true,"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 related insurance on your life or lives ever been postponed, declined or accepted on special terms? If yes, give details","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured member","type":"yes-no","label":"Has any of the persons to be insured suffer from/or investigated for any of the following: heart disorder, circulatory system, chest pain, high blood pressure, stroke, asthma, cancer, diabetes, hepatitis, urinary/kidney disorder, blood disorder, mental/psychiatric conditions, brain/nervous system disease, epilepsy, vertebral disorder, congenital defects, AIDS or HIV?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"","type":"choice","label":"Payment Mode","options":["Full Payment","Instalment Payment"],"required":true,"pdf_field":""},{"help":"Select payment mode","type":"choice","label":"Payment Details (Cash, Cheque, DD, Credit Card, Debit Card, UPI)","options":["Cash","Cheque","DD","Credit Card","Debit Card","UPI"],"required":true,"pdf_field":""},{"help":"Select who gave the check if applicable","type":"choice","label":"Check- Given By","options":["Spouse","Father","Mother","Son/Daughter","Employer/Employee","Financier"],"required":false,"pdf_field":""},{"help":"Enter payment amount","type":"amount","label":"Amount","options":[],"required":true,"pdf_field":""},{"help":"Enter transaction number if applicable","type":"text","label":"Transaction No.","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction date","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"BIMA ASBA Declaration and Bank Details","fields":[{"help":"Select if you want to open electronic insurance account","type":"yes-no","label":"Do you want to open e-IA account","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide bank details for e-IA account","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":""},{"help":"Select preferred contact mode","type":"choice","label":"In case of any Offer, you would prefer to be contacted by","options":["Phone","Email","WhatsApp"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Signature of agent or intermediary","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":""},{"help":"Enter witness name","type":"text","label":"Name of Witness","options":[],"required":false,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Declarations","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":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Apananka Pain- Odisha health insurance policy","attachments":[],"declarations":["The statements and particulars given are true and complete to the best of knowledge.","The policy will come into force only after full receipt and realization of premium.","Notify in writing any change in occupation or health after proposal submission before acceptance.","Consent to company seeking medical information from doctors, hospitals, employers for underwriting and claims.","Consent to share proposal and medical records with reinsurers and regulatory authorities.","Premium paid from legally acquired sources and future premiums will be similarly paid.","Consent to verify identity/address proof through CERSAI or NSDL for KYC.","Consent to share personal information with group companies for products and services."],"dropped_labels":10},"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/2141-proposal-form-apananka-pain-odisha"}