{"id":2180,"title":"PROPOSAL FORM AROGYA SANJEEVANI","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/digital-pf/Arogya-Sanjeevani-pf-digital.pdf","sha256":"9a208b9ad9c760c173401dec7897408cd73c80f10169d4d13377f60e5b5a79c3","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is a health insurance proposal form for the Arogya Sanjeevani Policy by Bajaj General Insurance. It is filled by the proposer (the person seeking insurance) to provide personal, health, and nominee details for policy issuance.","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.","Use original documents where required.","Nominee for self must be one of the specified relations.","Signature of proposer and intermediary is mandatory.","If proposer is disabled, authorised representative must sign the form.","No rebate of commission or premium is allowed as per Insurance Act 1938 Section 41."],"title":"PROPOSAL FORM AROGYA SANJEEVANI","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":"Title, First Name, Middle Name, Surname"},{"help":"Enter existing policy number if any","type":"text","label":"the Policy No.: OG","options":[],"required":false,"pdf_field":"Policy No OG"},{"help":"Enter your existing customer PID number if applicable","type":"text","label":"Existing Customer (PID) No.","options":[],"required":false,"pdf_field":"PID NO"},{"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"],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":"Gender.0"},{"help":"Enter your date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":"DOB"},{"help":"Enter your PAN number","type":"text","label":"Pan No.","options":[],"required":false,"pdf_field":"Pan No"},{"help":"Enter last 4 digits of your Aadhaar number","type":"text","label":"Aadhaar No. Enter last 4 digits only","options":[],"required":false,"pdf_field":"Aadhaar No"},{"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":"text","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":["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) in below table","options":[],"required":false,"pdf_field":"ABHA Number101.0"}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"Select your highest educational qualification","type":"choice","label":"Educational Qualification","options":["Matriculate","Under Graduate","Graduate","Post Graduate","Professionally Qualified"],"required":false,"pdf_field":""},{"help":"Enter your monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":"Monthly Income"},{"help":"Enter your nationality","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":"Nationality"},{"help":"Select the policy term","type":"choice","label":"Policy Term","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Select policy type","type":"choice","label":"Policy type","options":["Individual","Floater"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee's full name","type":"text","label":"Name","options":[],"required":true,"pdf_field":"NomineeName"},{"help":"Enter nominee's date of birth","type":"date","label":"DOB (dd/mm/yyyy)","options":[],"required":true,"pdf_field":"Nominee DOB"},{"help":"Enter nominee's age","type":"number","label":"Age","options":[],"required":true,"pdf_field":"AgeNominee"},{"help":"Enter relationship of nominee to proposer","type":"text","label":"Relation","options":[],"required":true,"pdf_field":"RelationNominee"},{"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":"If Nominee is Others please specify the relationship and reason"}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Do you smoke cigarettes or consume tobacco (chewing paste) / alcohol, nicotine or marijuana in any form?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide duration and daily consumption details if Yes","type":"text","label":"If Yes Please give duration and daily consumption","options":[],"required":false,"pdf_field":"If Yes Please give duration and daily consumption"},{"help":"Select Yes or No and provide details if Yes","type":"yes-no","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":"Select Yes or No","type":"yes-no","label":"Has any of the persons to be insured suffer from/or investigated for any of the following? (list of diseases)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have you or any of the persons proposed to be insured were/are detected as COVID positive?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","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 (self/ prescribed) or planned for any treatment / surgery / hospitalization?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of illness or injury for each person","type":"table","label":"If the reply is YES to any questions from a. to f. 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":"Member NameRow1_2, Name of the Illnessinjury suffered suffering in the pastRow1.0, Treatment detailsRow1.0, Date first treatedRow1.0, Current Status of the IllnessDiseasesInjuryRow1.0"},{"help":"Select Yes or No and provide age details if Yes","type":"yes-no","label":"Have any of your immediate family members (father, mother, brother or sister) have/ had diabetes, hypertension, cancer, heart attack, or stroke and at What age? If yes, was it before age 60 years or after 60 years?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide family medical history details","type":"table","label":"Member Name, Relationship with Proposer, Disease Name, At what Age illness suffered","options":[],"required":false,"pdf_field":"Member NameRow1_2, Relationship with ProposerRow1_2, Disease NameRow1, At whatAge illness sufferedRow1"}],"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/Employee"],"required":false,"pdf_field":""},{"help":"Consent for BIMA ASBA facility","type":"text","label":"BIMA ASBA Declaration (Applicable only in case Premium payment through online payment mode)","options":[],"required":false,"pdf_field":""},{"help":"Enter amount paid","type":"amount","label":"Amount","options":[],"required":false,"pdf_field":"Amount"},{"help":"Enter transaction number","type":"text","label":"Transaction No","options":[],"required":false,"pdf_field":"Transaction No"},{"help":"Enter transaction date","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":"TransationDate"},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":"Bank Name"},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":false,"pdf_field":"Branch"},{"help":"Provide e-IA number if available","type":"text","label":"Electronic-Insurance Account: Please provide e-IA No. to deposit your insurance policy","options":[],"required":false,"pdf_field":"Please provide eIA No to deposit your insurance policy"},{"help":"Select Yes or No","type":"yes-no","label":"Do you want to open e-IA account","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide bank account details for premium refund or policy deposit","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":"Name as per Bank Account, Name of the Bank, IFSC Code, Bank Account No, Account Type, Mobile No, Email Address"},{"help":"Select preferred contact mode for offers","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":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":"Place 3"},{"help":"Signature of insurance intermediary/agent","type":"signature","label":"Signature of Intermediary","options":[],"required":true,"pdf_field":"sign intermediary"},{"help":"Enter name of witness","type":"text","label":"Name of Witness","options":[],"required":false,"pdf_field":"Name of Witness"},{"help":"Signature of witness","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":"Signature of Witness"}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"Select if you have any physical deformity or handicap","type":"yes-no","label":"Any Physical deformity or handicap? Yes/No","options":["Yes","No"],"required":false,"pdf_field":"Disability Certificate"},{"help":"Provide details of disability and attach certificate","type":"text","label":"If Yes. Please provide details","options":[],"required":false,"pdf_field":"Disability Certificate"},{"help":"If proposer is disabled, authorised representative fills this","type":"text","label":"Name of Authorised Representative","options":[],"required":false,"pdf_field":"Name Of Authorised Representative"},{"help":"Date of authorised representative signature","type":"date","label":"Date","options":[],"required":false,"pdf_field":"Date 5"},{"help":"Signature of authorised representative","type":"signature","label":"Signature of Authorised Representative","options":[],"required":false,"pdf_field":"sign Authorised"},{"help":"Place of authorised representative signature","type":"text","label":"Place","options":[],"required":false,"pdf_field":"Place 5"}],"filled_by":"proposer or authorised representative"},{"title":"Agent Details and Declaration","fields":[{"help":"Enter agent or IMD name","type":"text","label":"Agent/IMD Name","options":[],"required":true,"pdf_field":"Agent Name"},{"help":"Enter agent or IMD code","type":"text","label":"Agent/IMD Code","options":[],"required":true,"pdf_field":"Agent Code"},{"help":"Agent or IMD signature","type":"signature","label":"Agent/IMD Signature","options":[],"required":true,"pdf_field":"sign Agent"},{"help":"Enter name of SP/BQP/DP/PoS if applicable","type":"text","label":"SP / BQP / DP / PoS Name","options":[],"required":false,"pdf_field":"SP / BQP / DP / PoS Name"},{"help":"Enter CoR number","type":"text","label":"SP / BQP / DP / PoS CoR No.","options":[],"required":false,"pdf_field":"SP / BQP / DP / PoS No"},{"help":"Signature of SP/BQP/DP/PoS","type":"signature","label":"SP / BQP / DP / PoS Signature","options":[],"required":false,"pdf_field":"sign pos"},{"help":"Agent signature","type":"signature","label":"Signature of Agent","options":[],"required":true,"pdf_field":"sign Agent"}],"filled_by":"agent"}],"deadlines":[],"applies_to":"Arogya Sanjeevani health insurance policy proposals","attachments":["Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability"],"declarations":["The proposer declares that all information given is true and complete to the best of their knowledge.","The policy will be issued only after full receipt and realization of premium.","The proposer will notify any change in occupation or health before risk acceptance.","The company may seek medical information from doctors, hospitals, employers, or other insurers for underwriting or claims.","The proposer consents to the company accessing and sharing ABHA data for underwriting and claims.","The company may share proposal and medical information with reinsurers and regulatory authorities.","Agent declares that the proposal form contents were explained to the proposer in vernacular language if required."],"dropped_labels":13},"pdf_fields":[{"name":"Scrutiny No","page":1,"type":"text","label":"Scrutiny No._Row_1"},{"name":"Receipt No","page":1,"type":"text","label":"Receipt No._Row_1"},{"name":"Policy No","page":1,"type":"text","label":"Policy No._Row_1"},{"name":"Loan Account No","page":1,"type":"text","label":"Loan Account Number_Row_1"},{"name":"EmpLG No","page":1,"type":"text","label":"Emp/LG Code_Row_1"},{"name":"IMD Code","page":1,"type":"text","label":"IMD Code_Row_1"},{"name":"Sub IMD Code","page":1,"type":"text","label":"Sub IMD Code_Row_1"},{"name":"IMD NameRow1","page":1,"type":"text","label":"IMD Name_Row_1"},{"name":"MobileNO","page":1,"type":"text","label":"Mobile_Row_1"},{"name":"Title","page":1,"type":"text","label":"First Name"},{"name":"First Name","page":1,"type":"text","label":"First Name"},{"name":"Middle Name","page":1,"type":"text","label":"First Name"},{"name":"Surname","page":1,"type":"text","label":"First Name"},{"name":"Policy No OG","page":1,"type":"text","label":"a. 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Income","page":1,"type":"text","label":"undefined"},{"name":"Nationality","page":1,"type":"text","label":"undefined"},{"name":"Group No9","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No9","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No9","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"DOB FROM","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Group No10","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No10","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"DOB TO","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Sr. No.0","page":1,"type":"text","label":"Nationality"},{"name":"M1","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.0","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.0","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.0","page":1,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.0","page":1,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.0","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0","page":1,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Sum Insured.0","page":1,"type":"text","label":"Nationality"},{"name":"Floater Sum Insured","page":1,"type":"text","label":"Nationality"},{"name":"ABHA Number101.0","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Sr. No.1","page":1,"type":"text","label":"Nationality"},{"name":"M2","page":1,"type":"text","label":"Ht. 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(cms)_(dd/mm"},{"name":"Relation1.2","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.2","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.2","page":1,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.2","page":1,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.2","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.2","page":1,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Sum Insured.2","page":1,"type":"text","label":"Nationality"},{"name":"ABHA Number101.2","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Sr. No.3","page":1,"type":"text","label":"Nationality"},{"name":"M3.1","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.3","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.3","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.3","page":1,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.3","page":1,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.3","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.3","page":1,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Sum Insured.3","page":1,"type":"text","label":"Nationality"},{"name":"ABHA Number101.3","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Sr. No.4","page":1,"type":"text","label":"Nationality"},{"name":"M3.2","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.4","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.4","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.4","page":1,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.4","page":1,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.4","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.4","page":1,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Sum Insured.4","page":1,"type":"text","label":"Nationality"},{"name":"ABHA Number101.4","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Sr. No.5","page":1,"type":"text","label":"Nationality"},{"name":"M3.3","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.5","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.5","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.5","page":1,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.5","page":1,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.5","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.5","page":1,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Sum Insured.5","page":1,"type":"text","label":"Nationality"},{"name":"ABHA Number101.6","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Sr. No.6","page":1,"type":"text","label":"Nationality"},{"name":"M3.4","page":1,"type":"text","label":"Ht. 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