{"id":2189,"title":"Global Personal Guard Proposal Form","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/digital-pf/Global-Personal-Guard-PF-Digital.pdf","sha256":"9b29eac4d4fafacaf006f7535742df15e5a5abde477f6442c7219bb51096d1d3","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for the Global Personal Guard insurance policy from Bajaj General Insurance Limited. The proposer fills it to provide personal, family, coverage, and payment details for the insurance proposal.","notes":["Answer all questions in BLOCK letters.","The liability of the company starts only after proposal acceptance and premium payment.","Use original documents for attachments.","Nominee for self must be a close family member (Father, Mother, Son, Daughter, Spouse, Other).","Adventure Sports Benefit and Children's Education Benefit require selection of Death or Permanent Total Disability cover.","EMI Payment Cover and Loan Protector Cover require submission of Loan Sanction Letter.","Travel Expenses Benefit requires Accidental Hospitalization cover.","Keep policy contact and bank details updated for faster service.","Policy copy will be sent digitally; tick box if physical copy is required.","If proposer does not understand English, form must be explained in vernacular and witnessed.","Provide ABHA number if registered under Ayushmaan Bharat Yojana.","Fill loan details only if opting for related covers.","Premium payment can be made by various modes including cash, cheque, card, UPI.","BIMA ASBA consent is required for online premium payment blocking.","Agent must sign and declare having explained the form to the proposer."],"title":"Global Personal Guard Proposal Form","submit":{"to":"Bajaj General Insurance Limited","how":"submit physically or as per company instructions","address":"Bajaj Insurance House, Airport Road, Yerawada, Pune - 411006"},"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":"Full Name Title"},{"help":"","type":"choice","label":"Are you an existing Bajaj General Customer:   Yes    No","options":["Yes","No"],"required":true,"pdf_field":"G1"},{"help":"If existing customer, provide policy number","type":"text","label":"The Policy No.: OG","options":[],"required":false,"pdf_field":"The Policy No OG"},{"help":"If existing customer, provide PID number","type":"text","label":"Existing Customer (PID) No.:","options":[],"required":false,"pdf_field":"Existing Customer 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":[],"required":false,"pdf_field":"G2"},{"help":"Provide employee code if applicable","type":"text","label":"Bajaj Employee Code, if Proposer is Bajaj General/Bajaj Life Employee:","options":[],"required":false,"pdf_field":"3 Bajaj Employee Code if Proposer is Bajaj GeneralBajaj Life Employee"},{"help":"","type":"choice","label":"Gender:    Male    Female    Other","options":["Male","Female","Other"],"required":true,"pdf_field":"G3"},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of Birth:","options":[],"required":true,"pdf_field":"5 Date of Birth"},{"help":"Enter your PAN number","type":"text","label":"Pan No.:","options":[],"required":true,"pdf_field":"6 Pan No"},{"help":"Enter your Aadhaar number","type":"text","label":"Aadhar ID:","options":[],"required":true,"pdf_field":"7 Aadhar ID"},{"help":"","type":"choice","label":"Marital Status:    Married    Single    Divorced    Widowed","options":["Married","Single","Divorced","Widowed"],"required":true,"pdf_field":"G4"},{"help":"Enter number of sons and daughters","type":"number","label":"No. of Children’s: Sons Daughters","options":[],"required":false,"pdf_field":"G5"},{"help":"","type":"choice","label":"Occupation:    Business    Salaried    Professional    Student    Housewife    Retired    Others","options":["Business","Salaried","Professional","Student","Housewife","Retired","Others"],"required":true,"pdf_field":"G6"},{"help":"If yes, provide ABHA number in next section","type":"choice","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana?    Yes    No","options":["Yes","No"],"required":true,"pdf_field":"G7"},{"help":"Provide full permanent residential address","type":"text","label":"Address Details a) Permanent /Residential Address House No: House Name: Landmark/Locality: Road/Area Name: City: State: Pin Code: Telephone (Res.): Telephone (Office): Mobile Number: E-mail:","options":[],"required":true,"pdf_field":"12 Address Details a Permanent Residential Address"}],"filled_by":"proposer"},{"title":"Communication Address","fields":[{"help":"Provide communication address where all communications will be sent","type":"text","label":"House No & Name: House Name: Landmark/Locality: Road/Area Name: City: State: Pin Code: Telephone (Res.): Telephone (Office): Mobile Number: E-mail:","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"","type":"choice","label":"Educational Qualification:    Matriculate    Undergraduate    Graduate    Postgraduate    Professionally Qualified","options":["Matriculate","Undergraduate","Graduate","Postgraduate","Professionally Qualified"],"required":true,"pdf_field":"G8"},{"help":"Enter monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":"ii Proposer Monthly Income Rs"},{"help":"Enter nationality","type":"text","label":"Nationality:","options":[],"required":true,"pdf_field":"iii Nationality"},{"help":"Enter citizenship","type":"text","label":"Citizenship:","options":[],"required":true,"pdf_field":"iv Citizenship"},{"help":"","type":"choice","label":"Policy Term:    1 Year    2 Years    3 Years","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":"G9"},{"help":"Enter start and end date of proposed insurance period","type":"date","label":"Proposed Period of insurance:  From: To:","options":[],"required":true,"pdf_field":"D1"},{"help":"","type":"choice","label":"Policy type:    Individual    Floater","options":["Individual","Floater"],"required":true,"pdf_field":"D2"}],"filled_by":"proposer"},{"title":"Details Of Persons to Be Insured","fields":[{"help":"Fill details for each person to be insured; include ABHA number if registered under Ayushmaan Bharat Yojana","type":"table","label":"Member Name, Relationship with Proposer, Date of Birth DD/MM/YYYY, Age, Gender, Ht (cm), Wt (kg), Gross Monthly Income, ABHA Number (14 Digits)","options":[],"required":true,"pdf_field":"Member NameRow1.0"}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Provide nominee details; nominee for self must be close family member","type":"table","label":"Name, DOB (dd/mm/yyyy), Age, Relationship with Proposer, Percentage of Nomination","options":[],"required":true,"pdf_field":"NameNominee"},{"help":"Explain relationship and reason if nominee is not a close family member","type":"text","label":"If Nominee is 'Others' please specify the relationship and reason","options":[],"required":false,"pdf_field":"reason"}],"filled_by":"proposer"},{"title":"Cover Details","fields":[{"help":"Select rider options if applicable","type":"choice","label":"Selection of Rider/Add on - Health Prime Rider: Co-Pay:  Yes    No; Plan Option; Individual or Floater","options":["Yes","No","Individual","Floater"],"required":false,"pdf_field":"Plan Option"}],"filled_by":"proposer"},{"title":"Loan Account Details","fields":[{"help":"Fill only if opting for Loan protector cover or EMI Payment cover","type":"text","label":"Bank Name, Address, Type of Loan, Loan Account Number, Sanctioned Loan Amount, Loan Period, EMI (Rs.)","options":[],"required":false,"pdf_field":"Bank Name"}],"filled_by":"proposer"},{"title":"Existing Insurance Details","fields":[{"help":"","type":"choice","label":"Are the persons insured under the policy, already insured under any similar kind of cover?    Yes    No","options":["Yes","No"],"required":true,"pdf_field":"G13"},{"help":"Provide details of existing insurance if any","type":"table","label":"Coverage, Name and Address of Insurance Company, Policy Number, Sum Insured, Period of Insurance From and To","options":[],"required":false,"pdf_field":"CoverageRow1"}],"filled_by":"proposer"},{"title":"Premium Payment Details","fields":[{"help":"","type":"choice","label":"Payment Options:    Full Payment    Instalment Payment:    Monthly    Quarterly    Half Yearly    Annual","options":["Full Payment","Monthly","Quarterly","Half Yearly","Annual"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Payment Mode:    Cash    Cheque    DD    Credit Card    Debit Card    UPI","options":["Cash","Cheque","DD","Credit Card","Debit Card","UPI"],"required":true,"pdf_field":""},{"help":"","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 transaction details for premium payment","type":"text","label":"Amount, Transaction No., Transaction Date, Bank Name, Branch","options":[],"required":false,"pdf_field":"Amount"}],"filled_by":"proposer"},{"title":"Electronic-Insurance Account","fields":[{"help":"Provide e-Insurance Account number if available","type":"text","label":"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 if you want to open an e-IA account","type":"choice","label":"Do you want to open e-IA account:    Yes    No","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer Bank Details","fields":[{"help":"Provide bank details for refund and policy servicing","type":"text","label":"Name as per Bank Account, Name of the Bank, IFSC Code, Bank Account No, Account Type, Mobile No, Email Address","options":[],"required":true,"pdf_field":"Name as per Bank Account"},{"help":"Tick to authorize refund to bank account","type":"checkbox","label":"I/We hereby authorize Bajaj General Insurance Limited to refund any amount related to my policy and/or claim directly credited to my aforesaid Bank Account and agree to inform if there is any change in the above contact or bank details.","options":[],"required":true,"pdf_field":""},{"help":"Select preferred contact method for offers","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":"Declaration and Consent","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":"S1"},{"help":"Agent or intermediary signature","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":"S2"},{"help":"Declare any physical disability and attach certificate","type":"choice","label":"Disability Declaration: Any Physical deformity or handicap?      Yes      No; If yes, provide details and disability certificate","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent Details and Declaration","fields":[{"help":"Agent fills and signs","type":"text","label":"Agent/IMD Name, Agent/IMD Code, Agent/IMD Signature, SP / BQP / DP / PoS Name, SP / BQP / DP / PoS CoR No., SP / BQP / DP / PoS Signature","options":[],"required":true,"pdf_field":"AgentIMD Code"},{"help":"Agent signature","type":"signature","label":"Signature of Agent","options":[],"required":true,"pdf_field":"Signature of Agent"}],"filled_by":"agent"},{"title":"Acknowledgment","fields":[{"help":"For office use only","type":"text","label":"Received from Ms./Mrs./Mr, sum of Rs, through Cash / Cheque / DD / Credit Card / Debit Card No, Date, Signature of Bajaj General Official/Intermediary, Time, Place, Bajaj General Official/Intermediary Name","options":[],"required":false,"pdf_field":"Receipt"}],"filled_by":"company"}],"deadlines":[],"applies_to":"Individual and Floater health insurance policies under Global Personal Guard","attachments":["Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability","Loan Sanction Letter (mandatory if opting for EMI Payment Cover or Loan Protector Cover)"],"declarations":["The information provided is true and complete to the best of the proposer's knowledge.","The policy will be effective only after acceptance by the company and full premium payment.","The proposer will notify any change in occupation or health before risk acceptance.","The company may seek medical and insurance information for underwriting and claims.","The company may share proposal and medical information with reinsurers and regulatory authorities.","Premiums are paid from legally acquired income sources.","Consent is given for KYC verification through CERSAI or NSDL portals.","Consent is given to share personal data with group companies for services and offers.","No rebates or inducements are allowed as per Insurance Act 1938 Section 41.","Politically Exposed Persons must declare their status.","Agent declares having explained the form contents to the proposer."],"dropped_labels":9},"pdf_fields":[{"name":"Receipt","page":1,"type":"text","label":"Receipt"},{"name":"EmpLG","page":1,"type":"text","label":"Emp/LG"},{"name":"Scrutiny NoRow1","page":1,"type":"text","label":"Scrutiny No._Row_1"},{"name":"Receipt NoRow1","page":1,"type":"text","label":"Receipt No._Row_1"},{"name":"Policy NoRow1","page":1,"type":"text","label":"Policy No._Row_1"},{"name":"Loan Account NoRow1","page":1,"type":"text","label":"Loan Account No._Row_1"},{"name":"EmpLG CodeRow1","page":1,"type":"text","label":"Emp/LG Code_Row_1"},{"name":"IMD CodeRow1","page":1,"type":"text","label":"IMD Code_Row_1"},{"name":"Sub IMD CodeRow1","page":1,"type":"text","label":"Sub IMD Code_Row_1"},{"name":"IMD NameRow1","page":1,"type":"text","label":"IMD Name_Row_1"},{"name":"Mobile NoRow1","page":1,"type":"text","label":"Mobile No._Row_1"},{"name":"Full Name Title","page":1,"type":"text","label":"Full Name: Title"},{"name":"First Name","page":1,"type":"text","label":"First Name"},{"name":"Middle Name","page":1,"type":"text","label":"Middle Name"},{"name":"Surname","page":1,"type":"text","label":"Surname"},{"name":"G1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"G1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"The Policy No OG","page":1,"type":"text","label":"The Policy No.: OG"},{"name":"Existing Customer PID No","page":1,"type":"text","label":"Existing Customer (PID) No"},{"name":"G2","page":1,"type":"radiobutton"},{"name":"3 Bajaj Employee Code if Proposer is Bajaj GeneralBajaj Life Employee","page":1,"type":"text","label":"3) Bajaj Employee Code, if Proposer is Bajaj General/Bajaj Life Employee"},{"name":"G3","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1"]},{"name":"G3","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1"]},{"name":"G3","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1"]},{"name":"5 Date of Birth","page":1,"type":"text","label":"5) Date of Birth"},{"name":"undefined","page":1,"type":"text","label":"undefined"},{"name":"undefined_2","page":1,"type":"text","label":"undefined"},{"name":"6 Pan No","page":1,"type":"text","label":"6) Pan No"},{"name":"7 Aadhar ID","page":1,"type":"text","label":"7) Aadhar ID"},{"name":"G4","page":1,"type":"radiobutton"},{"name":"G4","page":1,"type":"radiobutton"},{"name":"G4","page":1,"type":"radiobutton"},{"name":"G4","page":1,"type":"radiobutton"},{"name":"fill_16","page":1,"type":"text","label":" Business"},{"name":"fill_15","page":1,"type":"text","label":" Salaried"},{"name":"G5","page":1,"type":"radiobutton","options":["Choice4","Choice4","Choice4","Choice4","Choice4","Choice4","Choice4"]},{"name":"G5","page":1,"type":"radiobutton","options":["Choice4","Choice4","Choice4","Choice4","Choice4","Choice4","Choice4"]},{"name":"G5","page":1,"type":"radiobutton","options":["Choice4","Choice4","Choice4","Choice4","Choice4","Choice4","Choice4"]},{"name":"G5","page":1,"type":"radiobutton","options":["Choice4","Choice4","Choice4","Choice4","Choice4","Choice4","Choice4"]},{"name":"G5","page":1,"type":"radiobutton","options":["Choice4","Choice4","Choice4","Choice4","Choice4","Choice4","Choice4"]},{"name":"G5","page":1,"type":"radiobutton","options":["Choice4","Choice4","Choice4","Choice4","Choice4","Choice4","Choice4"]},{"name":"G5","page":1,"type":"radiobutton","options":["Choice4","Choice4","Choice4","Choice4","Choice4","Choice4","Choice4"]},{"name":"fill_4","page":1,"type":"text","label":" Others"},{"name":"G6","page":1,"type":"radiobutton","options":["Choice4","Choice4"]},{"name":"G6","page":1,"type":"radiobutton","options":["Choice4","Choice4"]},{"name":"12 Address Details a Permanent Residential Address","page":1,"type":"text","label":"12) Address Details: a) Permanent /Residential Address"},{"name":"undefined_3","page":1,"type":"text","label":"undefined"},{"name":"LandmarkLocality","page":1,"type":"text","label":"Landmark/Locality"},{"name":"RoadArea Name","page":1,"type":"text","label":"Road/Area Name"},{"name":"City","page":1,"type":"text","label":"City"},{"name":"undefined_4","page":1,"type":"text","label":"undefined"},{"name":"Pin Code","page":1,"type":"text","label":"Pin Code"},{"name":"Telephone Res","page":1,"type":"text","label":"Telephone (Res"},{"name":"undefined_5","page":1,"type":"text","label":"undefined"},{"name":"Telephone Office","page":1,"type":"text","label":"Telephone (Office"},{"name":"undefined_6","page":1,"type":"text","label":"undefined"},{"name":"undefined_7","page":1,"type":"text","label":"undefined"},{"name":"Email","page":1,"type":"text","label":"E-mail"},{"name":"House No  Name","page":2,"type":"text","label":"House No & Name"},{"name":"undefined_8","page":2,"type":"text","label":"undefined"},{"name":"LandmarkLocality_2","page":2,"type":"text","label":"Landmark/Locality"},{"name":"RoadArea Name_2","page":2,"type":"text","label":"Road/Area Name"},{"name":"City_2","page":2,"type":"text","label":"City"},{"name":"undefined_9","page":2,"type":"text","label":"undefined"},{"name":"Pin Code_2","page":2,"type":"text","label":"Pin Code"},{"name":"Telephone Res_2","page":2,"type":"text","label":"Telephone (Res"},{"name":"undefined_10","page":2,"type":"text","label":"undefined"},{"name":"Telephone Office_2","page":2,"type":"text","label":"Telephone (Office"},{"name":"undefined_11","page":2,"type":"text","label":"undefined"},{"name":"undefined_12","page":2,"type":"text","label":"undefined"},{"name":"Email_2","page":2,"type":"text","label":"E-mail"},{"name":"G7","page":2,"type":"radiobutton"},{"name":"G7","page":2,"type":"radiobutton"},{"name":"G7","page":2,"type":"radiobutton"},{"name":"G7","page":2,"type":"radiobutton"},{"name":"G7","page":2,"type":"radiobutton"},{"name":"ii Proposer Monthly Income Rs","page":2,"type":"text","label":"ii) Proposer Monthly Income: Rs"},{"name":"iii Nationality","page":2,"type":"text","label":"iii) Nationality"},{"name":"iv Citizenship","page":2,"type":"text","label":"iv) Citizenship"},{"name":"G8","page":2,"type":"radiobutton"},{"name":"G8","page":2,"type":"radiobutton"},{"name":"G8","page":2,"type":"radiobutton"},{"name":"D1","page":2,"type":"text","label":"Nominee Details:"},{"name":"D2","page":2,"type":"text","label":"Nominee Details:"},{"name":"G9","page":2,"type":"radiobutton"},{"name":"G9","page":2,"type":"radiobutton"},{"name":"Member NameRow1.0","page":2,"type":"text","label":"Member Name_Row_1"},{"name":"Relationship with ProposerRow1.0","page":2,"type":"text","label":"Relationship with Proposer_Row_1"},{"name":"Date of Birth DDMM YYYYRow1.0","page":2,"type":"text","label":"Date of Birth DD/MM/ YYYY_Row_1"},{"name":"AgeRow1.0","page":2,"type":"text","label":"Age_Row_1"},{"name":"GenderRow1.0","page":2,"type":"text","label":"Gender_Row_1"},{"name":"Ht cmRow1.0","page":2,"type":"text","label":"Ht (cm)_Row_1"},{"name":"Wt kgRow1.0","page":2,"type":"text","label":"Wt (kg)_Row_1"},{"name":"Gross Monthly IncomeRow1.0","page":2,"type":"text","label":"Gross Monthly Income_Row_1"},{"name":"ABHA Number 14 DigitsRow1.0","page":2,"type":"text","label":"ABHA Number (14 Digits)_Row_1"},{"name":"Member NameRow1.1","page":2,"type":"text","label":"Member Name_Row_1"},{"name":"Relationship with ProposerRow1.1","page":2,"type":"text","label":"Relationship with Proposer_Row_1"},{"name":"Date of Birth DDMM YYYYRow1.1","page":2,"type":"text","label":"Date of Birth DD/MM/ YYYY_Row_1"},{"name":"AgeRow1.1","page":2,"type":"text","label":"Age_Row_1"},{"name":"GenderRow1.1","page":2,"type":"text","label":"Gender_Row_1"},{"name":"Ht cmRow1.1","page":2,"type":"text","label":"Ht (cm)_Row_1"},{"name":"Wt kgRow1.1","page":2,"type":"text","label":"Wt (kg)_Row_1"},{"name":"Gross Monthly IncomeRow1.1","page":2,"type":"text","label":"Gross Monthly Income_Row_1"},{"name":"ABHA Number 14 DigitsRow1.1","page":2,"type":"text","label":"ABHA Number (14 Digits)_Row_1"},{"name":"Member NameRow1.2","page":2,"type":"text","label":"Member Name_Row_1"},{"name":"Relationship with ProposerRow1.2","page":2,"type":"text","label":"Relationship with Proposer_Row_1"},{"name":"Date of Birth DDMM YYYYRow1.2","page":2,"type":"text","label":"Date of Birth DD/MM/ YYYY_Row_1"},{"name":"AgeRow1.2","page":2,"type":"text","label":"Age_Row_1"},{"name":"GenderRow1.2","page":2,"type":"text","label":"Gender_Row_1"},{"name":"Ht cmRow1.2","page":2,"type":"text","label":"Ht (cm)_Row_1"},{"name":"Wt kgRow1.2","page":2,"type":"text","label":"Wt (kg)_Row_1"},{"name":"Gross Monthly IncomeRow1.2","page":2,"type":"text","label":"Gross Monthly Income_Row_1"},{"name":"ABHA Number 14 DigitsRow1.2","page":2,"type":"text","label":"ABHA Number (14 Digits)_Row_1"},{"name":"Member NameRow1.3","page":2,"type":"text","label":"Member Name_Row_1"},{"name":"Relationship with ProposerRow1.3","page":2,"type":"text","label":"Relationship with Proposer_Row_1"},{"name":"Date of Birth DDMM YYYYRow1.3","page":2,"type":"text","label":"Date of Birth DD/MM/ YYYY_Row_1"},{"name":"AgeRow1.3","page":2,"type":"text","label":"Age_Row_1"},{"name":"GenderRow1.3","page":2,"type":"text","label":"Gender_Row_1"},{"name":"Ht cmRow1.3","page":2,"type":"text","label":"Ht (cm)_Row_1"},{"name":"Wt kgRow1.3","page":2,"type":"text","label":"Wt (kg)_Row_1"},{"name":"Gross Monthly IncomeRow1.3","page":2,"type":"text","label":"Gross Monthly Income_Row_1"},{"name":"ABHA Number 14 DigitsRow1.3","page":2,"type":"text","label":"ABHA Number (14 Digits)_Row_1"},{"name":"Member NameRow1.4","page":2,"type":"text","label":"Member Name_Row_1"},{"name":"Relationship with ProposerRow1.4","page":2,"type":"text","label":"Relationship with Proposer_Row_1"},{"name":"Date of Birth DDMM YYYYRow1.4","page":2,"type":"text","label":"Date of Birth DD/MM/ YYYY_Row_1"},{"name":"AgeRow1.4","page":2,"type":"text","label":"Age_Row_1"},{"name":"GenderRow1.4","page":2,"type":"text","label":"Gender_Row_1"},{"name":"Ht cmRow1.4","page":2,"type":"text","label":"Ht (cm)_Row_1"},{"name":"Wt kgRow1.4","page":2,"type":"text","label":"Wt (kg)_Row_1"},{"name":"Gross Monthly IncomeRow1.4","page":2,"type":"text","label":"Gross Monthly Income_Row_1"},{"name":"ABHA Number 14 DigitsRow1.4","page":2,"type":"text","label":"ABHA Number (14 Digits)_Row_1"},{"name":"Member NameRow1.5","page":2,"type":"text","label":"Member Name_Row_1"},{"name":"Relationship with ProposerRow1.5","page":2,"type":"text","label":"Relationship with Proposer_Row_1"},{"name":"Date of Birth DDMM YYYYRow1.5","page":2,"type":"text","label":"Date of Birth DD/MM/ YYYY_Row_1"},{"name":"AgeRow1.5","page":2,"type":"text","label":"Age_Row_1"},{"name":"GenderRow1.5","page":2,"type":"text","label":"Gender_Row_1"},{"name":"Ht cmRow1.5","page":2,"type":"text","label":"Ht (cm)_Row_1"},{"name":"Wt kgRow1.5","page":2,"type":"text","label":"Wt (kg)_Row_1"},{"name":"Gross Monthly IncomeRow1.5","page":2,"type":"text","label":"Gross Monthly Income_Row_1"},{"name":"ABHA Number 14 DigitsRow1.5","page":2,"type":"text","label":"ABHA Number (14 Digits)_Row_1"},{"name":"G10","page":2,"type":"radiobutton"},{"name":"NameNominee","page":2,"type":"text","label":"Name_Nominee*"},{"name":"DOB ddmmyyyyNominee","page":2,"type":"text","label":"DOB (dd/mm/yyyy)_Nominee*"},{"name":"AgeNominee","page":2,"type":"text","label":"Age_Nominee*"},{"name":"Relationship with ProposerNominee","page":2,"type":"text","label":"Relationship with Proposer_Nominee*"},{"name":"Percentage of NominationNominee","page":2,"type":"text","label":"Percentage of Nomination_Nominee*"},{"name":"NameNominee_2","page":2,"type":"text","label":"Name_Nominee*"},{"name":"DOB ddmmyyyyNominee_2","page":2,"type":"text","label":"DOB (dd/mm/yyyy)_Nominee*"},{"name":"AgeNominee_2","page":2,"type":"text","label":"Age_Nominee*"},{"name":"Relationship with ProposerNominee_2","page":2,"type":"text","label":"Relationship with Proposer_Nominee*"},{"name":"Percentage of NominationNominee_2","page":2,"type":"text","label":"Percentage of Nomination_Nominee*"},{"name":"NameAppointee If nominee is minor","page":2,"type":"text","label":"Name_Appointee (If nominee is minor)"},{"name":"DOB ddmmyyyyAppointee If nominee is minor","page":2,"type":"text","label":"DOB (dd/mm/yyyy)_Appointee (If nominee is minor)"},{"name":"AgeAppointee If nominee is minor","page":2,"type":"text","label":"Age_Appointee (If nominee is minor)"},{"name":"Relationship with ProposerAppointee If nominee is minor","page":2,"type":"text","label":"Relationship with Proposer_Appointee (If nominee is minor)"},{"name":"Percentage of NominationAppointee If nominee is minor","page":2,"type":"text","label":"Percentage of Nomination_Appointee (If nominee is minor)"},{"name":"reason","page":2,"type":"text","label":"reason"},{"name":"Member DetailsRow1","page":3,"type":"text","label":"Member Details_Row_1"},{"name":"OccupationRow1","page":3,"type":"text","label":"Occupation_Row_1"},{"name":"Any Existing Disability InfirmityRow1","page":3,"type":"text","label":"Any Existing Disability/ Infirmity_Row_1"},{"name":"Sum InsuredRow1.0","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_2.0","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_3.0","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Member DetailsRow2","page":3,"type":"text","label":"Member Details_Row_2"},{"name":"OccupationRow2","page":3,"type":"text","label":"Occupation_Row_2"},{"name":"Any Existing Disability InfirmityRow2","page":3,"type":"text","label":"Any Existing Disability/ Infirmity_Row_2"},{"name":"Sum InsuredRow1.1","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_2.1","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_3.1","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Member DetailsRow3","page":3,"type":"text","label":"Member Details_Row_3"},{"name":"OccupationRow3","page":3,"type":"text","label":"Occupation_Row_3"},{"name":"Any Existing Disability InfirmityRow3","page":3,"type":"text","label":"Any Existing Disability/ Infirmity_Row_3"},{"name":"Sum InsuredRow1.2","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_2.2","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_3.2","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Member DetailsRow4","page":3,"type":"text","label":"Member Details_Row_4"},{"name":"OccupationRow4","page":3,"type":"text","label":"Occupation_Row_4"},{"name":"Any Existing Disability InfirmityRow4","page":3,"type":"text","label":"Any Existing Disability/ Infirmity_Row_4"},{"name":"Sum InsuredRow1.3","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_2.3","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_3.3","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Member DetailsRow5","page":3,"type":"text","label":"Member Details_Row_5"},{"name":"OccupationRow5","page":3,"type":"text","label":"Occupation_Row_5"},{"name":"Any Existing Disability InfirmityRow5","page":3,"type":"text","label":"Any Existing Disability/ Infirmity_Row_5"},{"name":"Sum InsuredRow1.4","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_2.4","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_3.4","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Member DetailsRow6","page":3,"type":"text","label":"Member Details_Row_6"},{"name":"OccupationRow6","page":3,"type":"text","label":"Occupation_Row_6"},{"name":"Any Existing Disability InfirmityRow6","page":3,"type":"text","label":"Any Existing Disability/ Infirmity_Row_6"},{"name":"Sum InsuredRow1.5","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_2.5","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_3.5","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Member NameRow1_2","page":3,"type":"text","label":"Member Name_Row_1"},{"name":"Sum InsuredRow1_4","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Death Sum InsuredRow1","page":3,"type":"text","label":"Death Sum Insured_Row_1"},{"name":"PTD Sum InsuredRow1","page":3,"type":"text","label":"PTD Sum Insured_Row_1"},{"name":"Sum InsuredRow1_5","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_6","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_7","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Sum InsuredRow1_8","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Member NameRow2_2","page":3,"type":"text","label":"Member Name_Row_2"},{"name":"Sum InsuredRow2_4","page":3,"type":"text","label":"Sum Insured_Row_2"},{"name":"Death Sum InsuredRow2","page":3,"type":"text","label":"Death Sum Insured_Row_2"},{"name":"PTD Sum InsuredRow2","page":3,"type":"text","label":"PTD Sum Insured_Row_2"},{"name":"Sum InsuredRow2_5","page":3,"type":"text","label":"Sum Insured_Row_2"},{"name":"Sum InsuredRow2_6","page":3,"type":"text","label":"Sum Insured_Row_2"},{"name":"Sum InsuredRow2_7","page":3,"type":"text","label":"Sum Insured_Row_2"},{"name":"Sum InsuredRow2_8","page":3,"type":"text","label":"Sum Insured_Row_2"},{"name":"Member NameRow3_2","page":3,"type":"text","label":"Member Name_Row_3"},{"name":"Sum InsuredRow3_4","page":3,"type":"text","label":"Sum Insured_Row_3"},{"name":"Death Sum InsuredRow3","page":3,"type":"text","label":"Death Sum Insured_Row_3"},{"name":"PTD Sum InsuredRow3","page":3,"type":"text","label":"PTD Sum Insured_Row_3"},{"name":"Sum InsuredRow3_5","page":3,"type":"text","label":"Sum Insured_Row_3"},{"name":"Sum InsuredRow3_6","page":3,"type":"text","label":"Sum Insured_Row_3"},{"name":"Sum InsuredRow3_7","page":3,"type":"text","label":"Sum Insured_Row_3"},{"name":"Sum InsuredRow3_8","page":3,"type":"text","label":"Sum Insured_Row_3"},{"name":"Member NameRow4_2","page":3,"type":"text","label":"Member Name_Row_4"},{"name":"Sum InsuredRow4_4","page":3,"type":"text","label":"Sum Insured_Row_4"},{"name":"Death Sum InsuredRow4","page":3,"type":"text","label":"Death Sum Insured_Row_4"},{"name":"PTD Sum InsuredRow4","page":3,"type":"text","label":"PTD Sum Insured_Row_4"},{"name":"Sum InsuredRow4_5","page":3,"type":"text","label":"Sum Insured_Row_4"},{"name":"Sum InsuredRow4_6","page":3,"type":"text","label":"Sum Insured_Row_4"},{"name":"Sum InsuredRow4_7","page":3,"type":"text","label":"Sum Insured_Row_4"},{"name":"Sum InsuredRow4_8","page":3,"type":"text","label":"Sum Insured_Row_4"},{"name":"Member NameRow5_2","page":3,"type":"text","label":"Member Name_Row_5"},{"name":"Sum InsuredRow5_4","page":3,"type":"text","label":"Sum Insured_Row_5"},{"name":"Death Sum InsuredRow5","page":3,"type":"text","label":"Death Sum Insured_Row_5"},{"name":"PTD Sum InsuredRow5","page":3,"type":"text","label":"PTD Sum Insured_Row_5"},{"name":"Sum InsuredRow5_5","page":3,"type":"text","label":"Sum Insured_Row_5"},{"name":"Sum InsuredRow5_6","page":3,"type":"text","label":"Sum Insured_Row_5"},{"name":"Sum InsuredRow5_7","page":3,"type":"text","label":"Sum Insured_Row_5"},{"name":"Sum InsuredRow5_8","page":3,"type":"text","label":"Sum Insured_Row_5"},{"name":"Member NameRow6_2","page":3,"type":"text","label":"Member Name_Row_6"},{"name":"Sum InsuredRow6_4","page":3,"type":"text","label":"Sum Insured_Row_6"},{"name":"Death Sum InsuredRow6","page":3,"type":"text","label":"Death Sum Insured_Row_6"},{"name":"PTD Sum InsuredRow6","page":3,"type":"text","label":"PTD Sum Insured_Row_6"},{"name":"Sum InsuredRow6_5","page":3,"type":"text","label":"Sum Insured_Row_6"},{"name":"Sum InsuredRow6_6","page":3,"type":"text","label":"Sum Insured_Row_6"},{"name":"Sum InsuredRow6_7","page":3,"type":"text","label":"Sum Insured_Row_6"},{"name":"Sum InsuredRow6_8","page":3,"type":"text","label":"Sum Insured_Row_6"},{"name":"Member NameRow1_3","page":3,"type":"text","label":"Member Name_Row_1"},{"name":"Sum InsuredRow1_9","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Per Day BenefitRow1","page":3,"type":"text","label":"Per Day Benefit_Row_1"},{"name":"Sum InsuredRow1_10","page":3,"type":"text","label":"Sum Insured_Row_1"},{"name":"Weekly Benefit AmountRow1","page":3,"type":"text","label":"Weekly Benefit Amount_Row_1"},{"name":"Sum Insured Rs25000Row1","page":3,"type":"text","label":"Sum Insured Rs.25.000_Row_1"},{"name":"Sum Insured Rs25000Row1_2","page":3,"type":"text","label":"Sum Insured Rs.25.000_Row_1"},{"name":"Member NameRow2_3","page":3,"type":"text","label":"Member Name_Row_2"},{"name":"Sum InsuredRow2_9","page":3,"type":"text","label":"Sum Insured_Row_2"},{"name":"Per Day BenefitRow2","page":3,"type":"text","label":"Per Day Benefit_Row_2"},{"name":"Sum InsuredRow2_10","page":3,"type":"text","label":"Sum Insured_Row_2"},{"name":"Weekly Benefit AmountRow2","page":3,"type":"text","label":"Weekly Benefit Amount_Row_2"},{"name":"Sum Insured Rs25000Row2","page":3,"type":"text","label":"Sum Insured Rs.25.000_Row_2"},{"name":"Sum Insured Rs25000Row2_2","page":3,"type":"text","label":"Sum Insured Rs.25.000_Row_2"},{"name":"Member NameRow3_3","page":3,"type":"text","label":"Member Name_Row_3"},{"name":"Sum InsuredRow3_9","page":3,"type":"text","label":"Sum Insured_Row_3"},{"name":"Per Day BenefitRow3","page":3,"type":"text","label":"Per Day Benefit_Row_3"},{"name":"Sum InsuredRow3_10","page":3,"type":"text","label":"Sum Insured_Row_3"},{"name":"Weekly Benefit AmountRow3","page":3,"type":"text","label":"Weekly Benefit Amount_Row_3"},{"name":"Sum Insured Rs25000Row3","page":3,"type":"text","label":"Sum Insured Rs.25.000_Row_3"},{"name":"Sum Insured Rs25000Row3_2","page":3,"type":"text","label":"Sum Insured Rs.25.000_Row_3"},{"name":"Member NameRow4_3","page":3,"type":"text","label":"Member Name_Row_4"},{"name":"Sum InsuredRow4_9","page":3,"type":"text","label":"Sum Insured_Row_4"},{"name":"Per Day BenefitRow4","page":3,"type":"text","label":"Per Day Benefit_Row_4"},{"name":"Sum InsuredRow4_10","page":3,"type":"text","label":"Sum Insured_Row_4"},{"name":"Weekly Benefit AmountRow4","page":3,"type":"text","label":"Weekly Benefit Amount_Row_4"},{"name":"Sum Insured Rs25000Row4","page":3,"type":"text","label":"Sum Insured Rs.25.000_Row_4"},{"name":"Sum Insured Rs25000Row4_2","page":3,"type":"text","label":"Sum Insured Rs.25.000_Row_4"},{"name":"Member NameRow5_3","page":3,"type":"text","label":"Member Name_Row_5"},{"name":"Sum InsuredRow5_9","page":3,"type":"text","label":"Sum Insured_Row_5"},{"name":"Per Day BenefitRow5","page":3,"type":"text","label":"Per Day Benefit_Row_5"},{"name":"Sum InsuredRow5_10","page":3,"type":"text","label":"Sum Insured_Row_5"},{"name":"Weekly Benefit AmountRow5","page":3,"type":"text","label":"Weekly Benefit Amount_Row_5"},{"name":"Sum Insured Rs25000Row5","page":3,"type":"text","label":"Sum Insured Rs.25.000_Row_5"},{"name":"Sum Insured Rs25000Row5_2","page":3,"type":"text","label":"Sum Insured Rs.25.000_Row_5"},{"name":"Member NameRow6_3","page":3,"type":"text","label":"Member Name_Row_6"},{"name":"Sum InsuredRow6_9","page":3,"type":"text","label":"Sum Insured_Row_6"},{"name":"Per Day BenefitRow6","page":3,"type":"text","label":"Per Day Benefit_Row_6"},{"name":"Sum InsuredRow6_10","page":3,"type":"text","label":"Sum Insured_Row_6"},{"name":"Weekly Benefit AmountRow6","page":3,"type":"text","label":"Weekly Benefit Amount_Row_6"},{"name":"Sum Insured Rs25000Row6","page":3,"type":"text","label":"Sum Insured Rs.25.000_Row_6"},{"name":"Sum Insured Rs25000Row6_2","page":3,"type":"text","label":"Sum Insured Rs.25.000_Row_6"},{"name":"G11","page":3,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"G11","page":3,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"G12","page":3,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"G12","page":3,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Plan Option","page":3,"type":"text","label":"Plan Option"},{"name":"Bank Name","page":4,"type":"text","label":"Bank Name"},{"name":"Address","page":4,"type":"text","label":"Address"},{"name":"Type of Loan","page":4,"type":"text","label":"Type of Loan"},{"name":"Loan Account Number","page":4,"type":"text","label":"Loan Account Number"},{"name":"Sanctioned Loan Amount","page":4,"type":"text","label":"Sanctioned Loan Amount"},{"name":"Loan Period","page":4,"type":"text","label":"Loan Period"},{"name":"EMI Rs","page":4,"type":"text","label":"EMI (Rs"},{"name":"G13","page":4,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"G13","page":4,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"CoverageRow1","page":4,"type":"text","label":"Coverage_Row_1"},{"name":"Name and Address of Insurance CompanyRow1","page":4,"type":"text","label":"Name and Address of Insurance Company_Row_1"},{"name":"Policy NumberRow1","page":4,"type":"text","label":"Policy Number_Row_1"},{"name":"Sum InsuredRow1_11","page":4,"type":"text","label":"Sum Insured_Row_1"},{"name":"Period of Insurance","page":4,"type":"text","label":"Period of Insurance"},{"name":"Period of Insurance 1","page":4,"type":"text","label":"Period of Insurance"},{"name":"CoverageRow2","page":4,"type":"text","label":"Coverage_Row_2"},{"name":"Name and Address of Insurance CompanyRow2","page":4,"type":"text","label":"Name and Address of Insurance Company_Row_2"},{"name":"Policy NumberRow2","page":4,"type":"text","label":"Policy Number_Row_2"},{"name":"Sum InsuredRow2_11","page":4,"type":"text","label":"Sum Insured_Row_2"},{"name":"Period of Insurance 2","page":4,"type":"text","label":"Period of Insurance"},{"name":"Period of Insurance 3","page":4,"type":"text","label":"Period of Insurance"},{"name":"G14","page":4,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"G14","page":4,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"G15","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2"]},{"name":"G15","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2"]},{"name":"G15","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2"]},{"name":"G15","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2"]},{"name":"G16","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2","Choice2","Choice2"]},{"name":"G16","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2","Choice2","Choice2"]},{"name":"G16","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2","Choice2","Choice2"]},{"name":"G16","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2","Choice2","Choice2"]},{"name":"G16","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2","Choice2","Choice2"]},{"name":"G16","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2","Choice2","Choice2"]},{"name":"G17","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2","Choice2","Choice2"]},{"name":"G17","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2","Choice2","Choice2"]},{"name":"G17","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2","Choice2","Choice2"]},{"name":"G17","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2","Choice2","Choice2"]},{"name":"G17","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2","Choice2","Choice2"]},{"name":"G17","page":4,"type":"radiobutton","options":["Choice1","Choice2","Choice3","Choice2","Choice2","Choice2"]},{"name":"G18","page":4,"type":"radiobutton"},{"name":"Amount","page":4,"type":"text","label":"Amount"},{"name":"Transaction No","page":4,"type":"text","label":"Transaction No"},{"name":"Transaction Date","page":4,"type":"text","label":"Transaction Date"},{"name":"Bank Name_2","page":4,"type":"text","label":"Bank Name"},{"name":"Branch","page":4,"type":"text","label":"Branch"},{"name":"Please provide eIA No to deposit your insurance policy","page":4,"type":"text","label":"Please provide e-IA No. to deposit your insurance policy"},{"name":"G19","page":4,"type":"radiobutton","options":["Choice2","Choice2"]},{"name":"G19","page":4,"type":"radiobutton","options":["Choice2","Choice2"]},{"name":"Name as per Bank Account","page":4,"type":"text","label":"Name as per Bank Account"},{"name":"Name of the Bank","page":4,"type":"text","label":"Name of the Bank"},{"name":"IFSC Code","page":4,"type":"text","label":"IFSC Code"},{"name":"Bank Account No","page":4,"type":"text","label":"Bank Account No"},{"name":"Account Type","page":4,"type":"text","label":"Account Type"},{"name":"Mobile No","page":4,"type":"text","label":"Mobile No"},{"name":"Email Address","page":4,"type":"text","label":"Email Address"},{"name":"G20","page":4,"type":"radiobutton"},{"name":"G21","page":4,"type":"radiobutton"},{"name":"G22","page":4,"type":"radiobutton"},{"name":"G23","page":4,"type":"radiobutton"},{"name":"D4","page":5,"type":"text","label":"Place"},{"name":"D5","page":5,"type":"text","label":"Place"},{"name":"D6","page":5,"type":"text","label":"Place"},{"name":"Place","page":5,"type":"text","label":"Place"},{"name":"S1","page":5,"type":"text","label":"Place"},{"name":"D7","page":5,"type":"text","label":"Place"},{"name":"Place_2","page":5,"type":"text","label":"Place"},{"name":"S3","page":5,"type":"text","label":"Place"},{"name":"S2","page":5,"type":"text","label":"Place"},{"name":"D8","page":5,"type":"text","label":"Place"},{"name":"Place_3","page":5,"type":"text","label":"Place"},{"name":"S4","page":5,"type":"text","label":"Place"},{"name":"Name of Witness","page":5,"type":"text","label":"Name of Witness"},{"name":"G24","page":5,"type":"radiobutton","options":["Choice2","Choice2"]},{"name":"G24","page":5,"type":"radiobutton","options":["Choice2","Choice2"]},{"name":"If yes Please provide details","page":5,"type":"text","label":"If yes. Please provide details"},{"name":"I","page":5,"type":"text","label":"I"},{"name":"D9","page":5,"type":"text","label":"Place"},{"name":"Place_4","page":5,"type":"text","label":"Place"},{"name":"S5","page":5,"type":"text","label":"Place"},{"name":"Name of Authorised Representative","page":5,"type":"text","label":"Name of Authorised Representative"},{"name":"S6","page":5,"type":"text","label":"Place"},{"name":"AgentIMD Code","page":5,"type":"text","label":"Agent/IMD Code"},{"name":"S7","page":5,"type":"text","label":"Place"},{"name":"S9","page":5,"type":"text","label":"Place"},{"name":"SP  BQP  DP  PoS CoR No","page":5,"type":"text","label":"SP / BQP / DP / PoS CoR No"},{"name":"S8","page":5,"type":"text","label":"Place"},{"name":"I_2","page":5,"type":"text","label":"I"},{"name":"D10","page":6,"type":"text","label":"Place"},{"name":"Place_5","page":6,"type":"text","label":"Place"},{"name":"S10","page":6,"type":"text","label":"Place"},{"name":"G25","page":6,"type":"radiobutton","options":["Choice2","Choice2"]},{"name":"G25","page":6,"type":"radiobutton","options":["Choice2","Choice2"]},{"name":"If yes please share the details","page":6,"type":"text","label":"If yes, please share the details"},{"name":"G26","page":6,"type":"radiobutton","options":["Choice2","Choice2"]},{"name":"G26","page":6,"type":"radiobutton","options":["Choice2","Choice2"]},{"name":"G27","page":6,"type":"radiobutton"},{"name":"Received from MsMrsMr","page":6,"type":"text","label":"Received from Ms./Mrs./Mr"},{"name":"sum of Rs","page":6,"type":"text","label":"sum of Rs"},{"name":"through Cash  Cheque  DD  Credit Card  Debit Card No","page":6,"type":"text","label":"through Cash# / Cheque / DD / Credit Card / Debit Card No"},{"name":"Date","page":6,"type":"text","label":"Date"},{"name":"Signature of Bajaj General OfficialIntermediary","page":6,"type":"signature","label":"Signature of Bajaj General Official/Intermediary"},{"name":"Time","page":6,"type":"text","label":"Time"},{"name":"Place_6","page":6,"type":"text","label":"Place"},{"name":"Bajaj General OfficialIntermediary Name","page":6,"type":"text","label":"Bajaj General Official/Intermediary Name"}],"fillable_pdf":true,"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/2189-global-personal-guard-proposal-form"}