{"id":2159,"title":"PROPOSAL FORM Tujya Khatir- Goa","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/aapke-liye/tujya-khatir-goa/Tujya_Khatir-Goa_Proposal_Form.pdf","sha256":"4ece845bf56ada0daa4a86e75a9b1a48651d44b67003013994054da00d5a68cd","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 Tujya Khatir- Goa health insurance policy.","notes":["Please answer all questions in BLOCK letters.","The liability of the company does not commence until the proposal is accepted and premium paid.","Provide all information fully and accurately.","Use original documents and provide additional information relevant to risk.","Nominee for primary insured must be one of specified relations or specify if others.","Once optional covers are opted, cannot opt out at subsequent renewals.","For instalment payment, select frequency and payment mode.","Signature/thumb impression of proposer and signatures of intermediary and witness required.","Submission of proposal or payment does not oblige the company to issue a policy."],"title":"PROPOSAL FORM Tujya Khatir- Goa","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":[],"required":false,"pdf_field":""},{"help":"Provide ABHA number if registered","type":"text","label":"If Yes please share your Ayushmaan Bharat Health Account Number (ABHA) No.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Enter full permanent address","type":"text","label":"Permanent /Residential Address","options":[],"required":true,"pdf_field":""},{"help":"Enter full communication address","type":"text","label":"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":"Enter appointee details if nominee is minor","type":"text","label":"Appointee (If nominee is minor)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Status","fields":[{"help":"Answer yes or no 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":[],"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","options":["Cash","Cheque","DD","Credit Card","Debit Card","UPI"],"required":true,"pdf_field":""},{"help":"Select who gave the cheque if applicable","type":"choice","label":"Check- Given By","options":["Spouse","Father","Mother","Son/Daughter","Employer/Employee","Financier"],"required":false,"pdf_field":""},{"help":"Enter amount paid","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 yes or no","type":"yes-no","label":"Do you want to open e-IA account","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account holder name","type":"text","label":"Name as per Bank Account","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No","options":[],"required":false,"pdf_field":""},{"help":"Enter account type","type":"text","label":"Account Type","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"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?","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Tujya Khatir- Goa health insurance policy","attachments":[],"declarations":["The information provided is true and complete to the best of knowledge.","Policy comes into force only after premium receipt and acceptance by the company.","Notify any change in occupation or health after proposal submission before acceptance.","Consent to company seeking medical and insurance information for underwriting and claims.","Consent to share proposal and medical records with reinsurers and regulatory authorities.","No person shall offer or accept rebates except as allowed by insurer's published prospectus.","Premium paid is from legally acquired sources.","Consent to KYC verification through authorized portals.","Consent to share personal data with group companies for products and services."],"dropped_labels":16},"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/2159-proposal-form-tujya-khatir-goa"}