{"id":2184,"title":"PROPOSAL FORM CRITI CARE","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/Criti-Care/Criti-Care_PF.pdf","sha256":"9ca7d1090e0f1c7eb5aa699cbbaf4fc4d3a6994fc8d533842f0b6c8afad45ebc","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for Criti Care insurance to be filled by the proposer (person seeking insurance). It collects personal, health, and insurance details to apply for the policy.","notes":["Answer all questions in BLOCK letters.","The liability of the company starts only after acceptance of proposal and premium payment.","Provide all information fully and accurately.","Nominee for self must be one of the specified close relations.","Use original documents for disability certificate if applicable.","Signature of intermediary and witness required if proposer does not understand English or did not fill form themselves.","No rebate of commission or premium is allowed as per Insurance Act 1938 Section 41.","Submission of proposal or payment does not oblige the company to issue policy.","If any question in health questionnaire is answered Yes, provide details in the table.","Preferred contact method for offers can be selected.","If paying by cheque, specify who gave the cheque.","Agent must sign and date the form after explaining contents to proposer."],"title":"PROPOSAL FORM CRITI CARE","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":"Check if no change in KYC details","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":"Select your gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter date of birth in DDMMYYYY format","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","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":"If Yes above, provide ABHA number","type":"text","label":"Ayushmaan Bharat Health Account Number (ABHA)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Fill your 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":""}],"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 monthly income in Rs.","type":"amount","label":"Proposer Monthly Income","options":[],"required":false,"pdf_field":""},{"help":"Select 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), Height (cms), Weight (kgs), Occupation, Gross Monthly Income, ABHA Number","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Fill nominee details; nominee for self must be close family","type":"text","label":"Name, DOB (dd/mm/yyyy), Age, Relation, Nominee, Appointee (if nominee is minor), Relationship and reason if nominee is 'Others'","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Selection of Rider/Add on","fields":[{"help":"Select rider options if applicable","type":"choice","label":"Health Prime Rider - Yes/No, Individual/Floater, Plan Option","options":["Yes","No","Individual","Floater"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance Information","fields":[{"help":"Enter amount applied for critical illness benefit","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 Bajaj General Insurance Limited? 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? 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":""},{"help":"Select Yes or No and provide details if Yes","type":"yes-no","label":"Have you smoked or used any substance or product containing tobacco, nicotine or marijuana? If yes, please state duration and average daily consumption and type","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Answer Yes or No","type":"yes-no","label":"1. Are you now in good health and entirely free from any mental or physical impairments or deformities?","options":[],"required":true,"pdf_field":""},{"help":"Provide height, weight change and reason","type":"text","label":"2. Height (Cm.) How much weight have you lost or gained over the last 12 months? Reason for weight change","options":[],"required":true,"pdf_field":""},{"help":"Answer Yes or No for each sub-question a to h","type":"yes-no","label":"3. Have you ever suffered or do you now suffer from diseases of circulatory, respiratory, genito-urinary, gastrointestinal, nervous system or mental disorders, diabetes, cancer, unexplained symptoms, or any other diseases?","options":[],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"5. Have you ever had or been advised to have hospital treatment or surgery?","options":[],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"6. Have you ever had or been advised to have a blood test for AIDS or an AIDS-related condition or been refused as a blood donor?","options":[],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"7. In the past 5 years, have you consulted a physician or had investigations other than routine employment or immigration?","options":[],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"8. Have you ever received or do you now receive any personal accident, disability benefit, or disability-related payments?","options":[],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"9. Are you at present or any time in past were on any medication, special diet, or treatment?","options":[],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"10. Have you ever taken narcotics or other habit forming drugs or been treated or advised in connection with alcohol or drugs?","options":[],"required":true,"pdf_field":""},{"help":"Provide name and address","type":"text","label":"15. Name and address of your regular medical consultant","options":[],"required":false,"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 person, Illness/Injury, Treatment details, Date first treated, Current status","options":[],"required":false,"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":"Select who gave the cheque if applicable","type":"choice","label":"Cheque Given By (Spouse, Father, Mother, Son/Daughter, Financer, Employer/Employee)","options":["Spouse","Father","Mother","Son/Daughter","Financer","Employer/Employee"],"required":false,"pdf_field":""},{"help":"Provide payment transaction details","type":"text","label":"Amount, Transaction No., Transaction Date, Bank Name, Branch","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"Sign and date the form","type":"signature","label":"Date, Place, Signature/Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"Declare any disability","type":"yes-no","label":"Any Physical deformity or handicap? Yes/No","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer or authorized representative"},{"title":"Acknowledgment","fields":[{"help":"Receipt details of payment","type":"text","label":"Received from Ms./Mrs./Mr., sum of Rs., through Cash/Cheque/DD/Credit Card/Debit Card No., against proposal for Health Policy, Date","options":[],"required":false,"pdf_field":""},{"help":"Official or intermediary signs receipt","type":"signature","label":"Signature of Bajaj General Official/Intermediary, Name, Time, Place","options":[],"required":false,"pdf_field":""}],"filled_by":"company official or intermediary"}],"deadlines":[],"applies_to":"Criti Care insurance proposal","attachments":["Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability"],"declarations":["The information provided is true and complete to the best of the proposer's knowledge.","The policy will commence only after acceptance and full premium payment.","The proposer will notify any change in occupation or health after submission and before acceptance.","Consent is given to the company to seek medical and personal information for underwriting and claims.","Consent is given to collect and share ABHA data with reinsurers, service providers, and regulatory authorities.","Agent declares having explained the form contents and consequences of untrue statements or non-disclosure.","Premium is paid from legally acquired sources and future premiums will be similarly paid."],"dropped_labels":30},"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/2184-proposal-form-criti-care"}