{"id":2190,"title":"LOAN CARE - PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/Loan-Care/Revised-Loan-Care-Proposal-Form.pdf","sha256":"ff82443cd6c65608a17c508e91dc82856d0c108dbd88f23135dc5a45ca65f756","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer applying for Loan Care insurance coverage. The proposer fills it to provide personal, loan, nominee, and insurance details for underwriting the policy.","notes":["It is essential to answer all questions fully and accurately to avoid claim rejection or policy avoidance.","If more space is needed, attach a separate sheet.","Sum Insured must be equal to sanctioned Loan Amount or 60 times monthly income, whichever is lower.","Policy Period must equal Loan Tenure, minimum 1 year and maximum 3 years.","Keep policy contact details updated for faster service.","Use DD/MM/YYYY format for dates."],"title":"LOAN CARE - PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"PROPOSER DETAILS","fields":[{"help":"","type":"text","label":"1) Name of the Proposer :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"2) Gender : Male                / Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"3) Date of Birth :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"4) Correspondence Address :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"5) Telephone Number (Landline) :","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile Number :","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"6) E-mail ID :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"7) Occupation : Salaried              /  Self-Employed","options":["Salaried","Self-Employed"],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"8) Monthly Income (in Rs.) :","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"LOAN DETAILS","fields":[{"help":"","type":"text","label":"1) Name of the Financier :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"2) Loan Account Number :","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"3) Sanctioned Loan Amount (in Rs.) :","options":[],"required":null,"pdf_field":""},{"help":"Enter number of years","type":"number","label":"4) Loan Tenure (in years) :","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"5) EMI (in Rs.) :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"6) Type of Loan","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"NOMINEE DETAILS","fields":[{"help":"","type":"text","label":"1. Name of the Nominee :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"2. Gender of the Nominee  : Male           / Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"3. Date of Birth of the Nominee :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"4. Relationship of the Nominee to the Proposer :","options":[],"required":null,"pdf_field":""},{"help":"","type":"section","label":"If Nominee is a Minor, please provide the following details w.r.t. Appointee who should be a Major as on date of this application and should be different from the Proposer.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"1. Name of the Appointee :","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"2. Gender of the Appointee : Male         / Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"3. Date of Birth of the Appointee :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"4. Relationship of the Appointee to the Nominee:","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"DETAILS OF ANY OTHER EXISTING HEALTH INSURANCE/ PERSONAL ACCIDENT POLICY","fields":[{"help":"Fill details in the table columns","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Table column","type":"number","label":"S. No.","options":[],"required":null,"pdf_field":""},{"help":"Table column","type":"text","label":"Name and Address of Insurance Company","options":[],"required":null,"pdf_field":""},{"help":"Table column","type":"date","label":"From dd/mm/yy","options":[],"required":null,"pdf_field":""},{"help":"Table column","type":"date","label":"To dd/mm/yy","options":[],"required":null,"pdf_field":""},{"help":"Table column","type":"text","label":"Period of Insurance","options":[],"required":null,"pdf_field":""},{"help":"Table column","type":"amount","label":"Claims Received/ Receivable(in Rs.)","options":[],"required":null,"pdf_field":""},{"help":"Table column","type":"text","label":"Claimed for (Nature of Problems)","options":[],"required":null,"pdf_field":""},{"help":"Table column","type":"number","label":"No Claim Bonus%","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Ayushmaan Bharat Yojana Details","fields":[{"help":"","type":"yes-no","label":"4 a) Are you or any of your family members registered under the Ayushmaan Bharat Yojana? If yes please share your Ayushmaan Bharat Health Account Number (ABHA) in the below table","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill in the table","type":"text","label":"Member Name","options":[],"required":null,"pdf_field":""},{"help":"Table column","type":"number","label":"S. No.","options":[],"required":null,"pdf_field":""},{"help":"Enter 14 digit ABHA number","type":"text","label":"ABHA Number (14 Digits)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"PREMIUM DETAILS","fields":[{"help":"Sum Insured must be equal to sanctioned Loan Amount or 60 times monthly income, whichever is lower","type":"amount","label":"1) Sum Insured (in Rs.):","options":[],"required":true,"pdf_field":""},{"help":"Policy Period must equal Loan Tenure, minimum 1 year and maximum 3 years","type":"number","label":"2) Policy Period (in years):","options":[],"required":true,"pdf_field":""},{"help":"","type":"amount","label":"3) Total Premium {inclusive of Service Tax}(in Rs.) :","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"PAYMENT DETAILS","fields":[{"help":"","type":"section","label":"1) By Cheque :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"a) Cheque No. :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"b) Bank :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"c) Branch :","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"2) By Cash :","options":["By Cash"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"ILLNESS/INJURY DETAILS OF THE PAST 4 YEARS AND PRIOR TO 4 YEARS","fields":[{"help":"Table column","type":"number","label":"S. No.","options":[],"required":null,"pdf_field":""},{"help":"Table column","type":"text","label":"Name of the Illness / injury suffered / suffering in the past 4 years","options":[],"required":null,"pdf_field":""},{"help":"Table column","type":"text","label":"Name of the Illness / injury suffered any time in the past (prior to 4 years)","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"DECLARATION AND CONSENTS","fields":[{"help":"Enter date of signing in DD/MM/YYYY format","type":"date","label":"Date :","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place :","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"PEP means Politically Exposed Persons","type":"yes-no","label":"Are you or any of the proposal applicants a PEP* or a close relative of PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if PEP","type":"text","label":"If yes, please share the details","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"I/we hereby give my/our consent to the Company to verify and obtain my/our identity/address proof through CERSAI records or National Securities Depository Limited Portal for the purpose of undertaking KYC verification.","options":["Consent given"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"I/we hereby declare and confirm that the premium has been paid out of legally acquired sources of income and the subsequent premiums if any, will continue to be paid out of legally declared and assessed source of income.","options":["Declaration agreed"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"I/We hereby give voluntary consent to Bajaj General/Company to share my/our personal information and data provided in this proposal for its group companies or any other person in connection with the Insurance Policy or otherwise, including for providing products and services of group companies that may be of interest to me/us, to be used in accordance with their respective privacy policies and subject to appropriate measures being in place to safeguard my/our personal information.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Loan Care insurance proposal","attachments":["If there is insufficient space in this proposal for you to provide relevant information, please attach a separate sheet."],"declarations":["The statements and particulars given are true and complete to the best of the proposer's knowledge.","The policy will come into force only after full receipt of the premium.","The proposer will notify any change in occupation or health after submission but before acceptance.","The company may seek medical information from doctors, hospitals, past or present employers, and other insurance companies for underwriting and claim settlement.","The company may share proposal information including medical records with government and regulatory authorities.","No person shall offer or accept any rebate of commission or premium except as allowed by the insurer's published prospectus.","Non-compliance with rebate provisions may lead to penalty up to ten lakhs rupees.","The proposer consents to KYC verification through CERSAI or NSDL portals.","The premium has been paid from legally acquired sources and future premiums will be similarly paid.","The proposer consents to sharing personal information with group companies for products and services."],"dropped_labels":4},"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/2190-loan-care-proposal-form"}