{"id":2171,"title":"PROPOSAL FORM AapKe Liye- Bihar & Jharkhand","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/aapke-liye/aapke-liye-bihar-jharkhand/AapKe_Liye-Bihar_Jharkhand_Proposal_Form.pdf","sha256":"20989c637edb02c70bb37d8fefea374b3ab5641f8581d3a34b890ddc2e9f73e7","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a health insurance proposal form to be filled by the proposer (policyholder) applying for the AapKe Liye- Bihar & Jharkhand 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.","This proposal is the basis of the policy issued; provide all information fully and accurately.","Use original documents and provide additional information relevant to risk if requested.","Nominee for primary insured must be one of specified relations or specify if 'Others'.","Optional covers once opted cannot be opted out at subsequent renewals.","For payment by cheque, specify who gave the cheque.","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 AapKe Liye- Bihar & Jharkhand","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 policyholder, enter policy number","type":"text","label":"The Policy No.","options":[],"required":false,"pdf_field":""},{"help":"If existing customer, enter PID number or confirm no change in KYC","type":"text","label":"Existing Customer (PID) No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender : Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter date of birth 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":"Provide consent for credit score discount if applicable","type":"yes-no","label":"Do you wish to avail credit score discount if yes please provide below consent CIBIL Discount.","options":["Yes","No"],"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: 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 occupation","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":"If Yes, provide ABHA number in the table below","type":"yes-no","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":"Enter 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":""},{"help":"","type":"choice","label":"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 person to be insured","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 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":"Select sum insured and optional covers for each insured member","type":"table","label":"Member Name Sum Insured (Individual) Sum Insured (Floater) Optional Covers - Cover Name and selection for each insured","options":["Sum Insured Reinstatement: Once, Unlimited","Super Cumulative Bonus: 25% max 100%, 25% max 200%, 50% max 100%","Procedure wise/ Disease wise sub-limit: Yes, No","Cashless Discount: Yes, No","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":"Loyalty Discount","fields":[{"help":"Enter policy number, period, and line of business for each member","type":"table","label":"Do you have Motor, Health/ Personal Accident, Home, Cyber and Pet Insurance with premium > INR 2500? Provide policy details","options":[],"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":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Details","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":"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":"Specify 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 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":"","type":"yes-no","label":"Do you want to open e-IA account? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"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":"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"}],"deadlines":[],"applies_to":"AapKe Liye- Bihar & Jharkhand health insurance policy","attachments":[],"declarations":["The information provided is true and complete to the best of knowledge and forms the basis of the policy.","Policy comes 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 future premiums will be similarly paid."],"dropped_labels":15},"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/2171-proposal-form-aapke-liye-bihar-and-jharkhand"}