{"id":2146,"title":"PROPOSAL FORM Na Ka bynta jong phi- Meghalaya","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/aapke-liye/na-ka-bynta-jong-phi-meghalaya/Na_Ka_bynta_jong_phi-Meghalaya_Proposal_Form.pdf","sha256":"fcbaab0f911e3aa1267179d4a8e1a377337f806e90d5dad2116b9aaed4522f26","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 health insurance coverage under 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 including any additional relevant information.","Use original documents and provide accurate details to avoid delays.","Once optional covers are opted, they cannot be opted out at subsequent renewals.","Nominee for primary insured must be one of the specified relations or specify if 'Others'.","For all family members, primary insured will be the nominee.","Submission of proposal or payment does not oblige the company to issue a policy.","Signature and thumb impression required on the form.","Use the form as per instructions and provide all required details to avoid rejection."],"title":"PROPOSAL FORM Na Ka bynta jong phi- Meghalaya","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":"Provide 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":""},{"help":"Enter telephone number","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":false,"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":"Enter start date in DD/MM/YYYY","type":"date","label":"Period of insurance From","options":[],"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":"Provide nominee details","type":"table","label":"Name, DOB (dd/mm/yyyy), Age, Relation","options":[],"required":true,"pdf_field":""},{"help":"Provide appointee details if nominee is minor","type":"text","label":"Appointee (If nominee is minor)","options":[],"required":false,"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":"Enter sum insured details for each member","type":"table","label":"Member Name, Sum Insured (Individual), Sum Insured (Floater)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Optional Covers","fields":[{"help":"Select one option if opting for reinstatement","type":"choice","label":"Sum Insured Reinstatement","options":["Once","Unlimited"],"required":false,"pdf_field":""},{"help":"Select applicable bonus option","type":"choice","label":"Super Cumulative Bonus","options":["25% of SI max 100%","25% of SI max 200%","50% of SI max 100%"],"required":false,"pdf_field":""},{"help":"Select if opting for sub-limit","type":"yes-no","label":"Procedure wise/ Disease wise sub-limit","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if opting for cashless discount","type":"yes-no","label":"Cashless Discount","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select copayment percentage if applicable","type":"choice","label":"Voluntary Copayment","options":["5%","10%","15%","20%"],"required":false,"pdf_field":""},{"help":"Select deductible amount if applicable","type":"choice","label":"Voluntary Aggregate Deductible","options":["10,000","20,000","30,000","40,000","50,000","1,00,000","2,00,000","3,00,000"],"required":false,"pdf_field":""},{"help":"Can opt only at inception/renewal for proposer only","type":"yes-no","label":"Accidental Death Cover","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Loyalty Discount","fields":[{"help":"If yes, provide policy details in table","type":"yes-no","label":"Do you have Motor, Health/ Personal Accident, Home, Cyber and Pet Insurance with a premium more than INR 2500?","options":["Yes","No"],"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","fields":[{"help":"Select payment mode","type":"choice","label":"Payment Mode","options":["Full Payment","Instalment Payment"],"required":true,"pdf_field":""},{"help":"Select payment method","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 e-IA 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 premium payment","type":"text","label":"Bank Details: Name as per Bank Account, Name of the Bank, IFSC Code, Bank Account No, Account Type","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number linked to bank account","type":"phone","label":"Mobile No.","options":[],"required":false,"pdf_field":""},{"help":"Enter email address linked to bank account","type":"email","label":"Email Address","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of the 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"}],"deadlines":[],"applies_to":"Health insurance proposal for individual or floater policies under Bajaj General Insurance Limited","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 but before acceptance.","Consent to company seeking medical information from doctors, hospitals, employers for underwriting and claims.","Consent to share proposal and medical records with reinsurer, government and regulatory authorities.","No person shall offer or accept any rebate other than as allowed by insurer's published prospectus.","Consent to verify identity/address proof through CERSAI or NSDL portal for KYC verification.","Declaration that premium is paid from legally acquired sources and future premiums will be similarly paid.","Consent to share personal information with group companies for products and services."],"dropped_labels":17},"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/2146-proposal-form-na-ka-bynta-jong-phi-meghalaya"}