{"id":2179,"title":"PROPOSAL FORM CRITICAL ILLNESS","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/critical-illness/Critial_Illness_PF.pdf","sha256":"55995b4483bea45b8eaf93e6864cde74be594102606414f622794832fe193d60","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for critical illness insurance to be filled by the proposer (person seeking insurance).","notes":["Answer all questions in BLOCK letters.","The liability of the company does not commence until proposal is accepted and premium paid.","Provide all information fully and accurately.","Nominee for self must be one of the specified relations; for family members, primary insured will be nominee.","Use original documents and certificates where applicable.","If form is filled in vernacular language or by someone else, intermediary must sign to confirm explanation.","No rebate of commission or premium is allowed as per Insurance Act 1938 Section 41.","Submission of proposal or payment does not oblige company to issue policy.","If proposer has disability, authorized representative may sign declaration."],"title":"PROPOSAL FORM CRITICAL ILLNESS","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 if you are an existing customer","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":["I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter your date of birth (DD/MM/YYYY)","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Enter your PAN number","type":"text","label":"Pan No.","options":[],"required":false,"pdf_field":""},{"help":"Enter last 4 digits of Aadhaar number","type":"text","label":"Aadhaar No. Enter last 4 digits only","options":[],"required":false,"pdf_field":""},{"help":"Select your marital status","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":"Select your occupation or specify if Other","type":"choice","label":"Occupation","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana?","options":[],"required":false,"pdf_field":""},{"help":"Enter ABHA number if applicable","type":"text","label":"If Yes please share your Ayushmaan Bharat Health Account Number (ABHA) in below table","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Enter your communication address 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":""}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"Select your highest educational qualification","type":"choice","label":"Educational Qualification","options":["Matriculate","Undergraduate","Graduate","Post Graduate","Professionally Qualified"],"required":false,"pdf_field":""},{"help":"Enter your nationality","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":""},{"help":"Enter your monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":""},{"help":"Select the policy term","type":"choice","label":"Policy Term","options":["1 Year","2 Years","3 Years"],"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":"Name, Relationship with Proposer, DOB (dd/mm/yyyy), Age, Gender (M/F), Ht. (cms), Wt. (kgs), ABHA Number","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee details; nominee must be close family member or specify relationship if 'Others'","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":""}],"filled_by":"proposer"},{"title":"Selection of Rider/Add on","fields":[{"help":"Select if you want Health Prime Rider","type":"choice","label":"Health Prime Rider","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select plan option","type":"choice","label":"Plan Option","options":["Individual","Floater"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance Information","fields":[{"help":"Enter sum insured amount","type":"amount","label":"Critical illness benefit applied for Rs.","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No and provide policy number if Yes","type":"yes-no","label":"Do you have other current or pending critical illness Insurance with BGIL ? If Yes , Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No and provide details if Yes","type":"yes-no","label":"Do you have other current or pending critical illness Insurance with another Company ? If Yes, Name of Institution, Sum Insured, Year","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No and provide details if Yes","type":"yes-no","label":"Has any proposal for Life, Accident, Disability cover, Critical Illness or any other Health-Related Insurance on your life ever been postponed, declined or accepted on special terms? If yes, give details including amount applied for","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Answer all health questions truthfully","type":"yes-no","label":"Answer all questions by checking either the yes or no box (15 questions on health, medical history, habits, etc.)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details for any yes answers","type":"table","label":"If the reply is YES to any questions from 1. to 15. above, please share details in below table: Name of the person, Name of the Illness/injury suffered/suffering in the past, Treatment details, Date first treated, Current Status of the Illness/Diseases/Injury","options":[],"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","options":["Cash","Cheque","DD","Credit Card","Debit Card","UPI"],"required":true,"pdf_field":""},{"help":"Select who gave the cheque if applicable","type":"choice","label":"Cheque Given By","options":["Spouse","Father","Mother","Son/Daughter","Financer","Employer"],"required":false,"pdf_field":""},{"help":"Check if paying via BIMA ASBA","type":"checkbox","label":"BIMA ASBA Declaration (Applicable only in case Premium payment through online payment mode)","options":["I authorize BIMA ASBA facility to debit my bank account upon acceptance of this proposal"],"required":false,"pdf_field":""},{"help":"Provide transaction details if applicable","type":"text","label":"Amount, Transaction No., Transaction Date, Bank Name, Branch","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Do you want to open e-IA account","options":[],"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, Mobile No, Email Address","options":[],"required":false,"pdf_field":""},{"help":"Select preferred contact method","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":"Declaration","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Intermediary signs if form filled in vernacular language","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"Declare if any physical disability","type":"yes-no","label":"Any Physical deformity or handicap? Yes/No","options":[],"required":false,"pdf_field":""},{"help":"Provide details and attach Disability Certificate if applicable","type":"text","label":"If Yes. Please provide details","options":[],"required":false,"pdf_field":""},{"help":"Authorized representative signs if proposer has disability","type":"signature","label":"Name of Authorised Representative, Date, Signature, Place","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer or authorized representative"},{"title":"Agent Details and Declaration","fields":[{"help":"Agent fills and signs","type":"signature","label":"Agent/IMD Name, Agent/IMD Code, Agent/IMD Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"},{"title":"Acknowledgment","fields":[{"help":"Company official fills receipt details","type":"text","label":"Received from Ms. / Mrs. / Mr: sum of Rs. through Cash# / Cheque / DD / Credit Card / Debit Card No. against your proposal for Health Policy. Date","options":[],"required":false,"pdf_field":""},{"help":"Company official or intermediary signs","type":"signature","label":"Signature of Bajaj General Official/ Intermediary, Name, Time, Place","options":[],"required":false,"pdf_field":""}],"filled_by":"company official or intermediary"},{"title":"PEP Declaration and Consent","fields":[{"help":"Declare if Politically Exposed Person","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":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Critical Illness insurance policies","attachments":["Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability (if applicable)"],"declarations":["The statements and particulars given are true and complete to the best of knowledge.","The policy will come into force only after full payment 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, and insurers for underwriting and claims.","Consent to company collecting and sharing personal and medical information from ABHA for underwriting and claims.","Agent declaration that form contents were explained to proposer and consequences of non-disclosure were clarified.","Declaration that premium is paid from legally acquired sources.","Consent to verify identity/address proof through CERSAI or NSDL for KYC verification.","Consent to share personal information with Bajaj General and group companies."],"dropped_labels":13},"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/2179-proposal-form-critical-illness"}