{"id":2162,"title":"I tan- Mizoram Policy Wordings","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/aapke-liye/i-tan-mizoram/I_tan-Mizoram_Proposal_Form.pdf","sha256":"a5dc992b11609972da8ea30d6932ac6c1068e3890596bddb70708282f688cdac","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a health insurance proposal form to be filled by the proposer (policy applicant) to apply for an individual or floater 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 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.","The form content and particulars have to be explained in vernacular language if required.","Submission of proposal or payment does not oblige the company to issue a policy."],"title":"I tan- Mizoram Policy Wordings","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":"Enter existing customer ID if any","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 : Male Female Other","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","type":"text","label":"UID/Aadhaar No. Enter last 4 digits only","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status: Married Single Divorced Widowed","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","type":"choice","label":"Occupation Business Salaried Professional Student House wife Retired Other","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana? Yes No","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":""},{"help":"","type":"choice","label":"Other Details i. Educational Qualification Matriculate Under Graduate Graduate Post Graduate Professionally Qualified","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: 1 Year 2 Years 3 Years","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy type Individual Floater","options":["Individual","Floater"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details Of Persons To Be Insured","fields":[{"help":"Fill details for each insured member","type":"table","label":"Member Name DOB Age Gender Ht. (cms) Wt. (kgs) Occupation Relation Nationality ABHA Number","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee details","type":"text","label":"Name DOB (dd/mm/yyyy) Age Relation Nominee","options":[],"required":true,"pdf_field":""},{"help":"Enter 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":"Health Status","fields":[{"help":"Answer for each insured member","type":"choice","label":"Do you smoke cigarettes or consume tobacco (chewing paste) / alcohol, nicotine or marijuana in any form? Please give duration and daily consumption?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured member and provide details if yes","type":"choice","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":"choice","label":"Has any of the persons to be insured suffer from/or investigated for any of the following: Disorder of the heart, circulatory system, chest pain, high blood pressure, stroke, asthma, cancer, diabetes, hepatitis, kidney disorders, blood disorder, mental or psychiatric conditions, brain or nervous system diseases, epilepsy, backache, congenital defects, AIDS or HIV?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer for each insured member","type":"choice","label":"Do you or any of the family members to be covered have/had any health complaints/met with any accident in the past 4 years and prior to 4 years and have been taking treatment, regular medication or planned for any treatment/surgery/hospitalization?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"Select payment mode and frequency","type":"choice","label":"Payment Mode Full Payment Instalment Payment Monthly Quarterly Half Annual","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":"Who gave the cheque if applicable","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":""},{"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 if you want to open electronic insurance account","type":"choice","label":"Do you want to open e-IA account Yes No","options":["Yes","No"],"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 linked to bank","type":"phone","label":"Mobile No","options":[],"required":false,"pdf_field":""},{"help":"Enter email address linked to bank","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: Phone Email WhatsApp","options":["Phone","Email","WhatsApp"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Sign or put 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 Person declaration","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":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Health insurance individual or floater policies under UIN BAJHLIP26060V012526","attachments":[],"declarations":["The statements and particulars given are true and complete to the best of the proposer's 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 reinsurers and regulatory authorities.","No rebate of commission or premium is allowed as inducement to take or renew insurance.","Premium paid is from legally acquired sources and subsequent premiums will be similarly paid.","Consent to verify identity/address through CERSAI or NSDL for KYC verification.","Consent to share personal information with group companies for products and services."],"dropped_labels":6},"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/2162-i-tan-mizoram-policy-wordings"}