{"id":2192,"title":"PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/Nidaan-Swasthya-Bima/NSB-PF.pdf","sha256":"588356f95b73b64e27115232d6826abd39e827e97740b7c59b6605e1b78f4648","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is a health insurance policy proposal for the Nidaan Swasthya Bima plan, to be filled by the proposer (person seeking insurance).","notes":["Answer all questions in BLOCK letters.","Only Indian Nationals can be covered under this policy.","Persons with Disability must have 40% disability certified by competent authority as per Disability Act 2016.","Persons with HIV/AIDS with CD4 count above 400 are eligible.","Information for fields marked with asterisk (*) are mandatory.","Nominee for self must be Father, Mother, Son, Daughter, Spouse or Other.","Use original certificates for CD4 count and disability.","Submission of proposal or payment does not oblige the company to issue policy.","No rebate of commission or premium is allowed as per Insurance Act 1938 Section 41."],"title":"PROPOSAL FORM","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":"If existing customer, enter PID number","type":"text","label":"Existing Customer (PID) No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy","options":["Yes"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Enter 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":"","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":"If Other, specify","type":"choice","label":"Occupation","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":false,"pdf_field":""},{"help":"","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 registered under Ayushmaan Bharat, provide ABHA number","type":"text","label":"Ayushmaan Bharat Health Account Number (ABHA)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"Policy type is Individual Basis","type":"text","label":"Policy Type","options":["Individual Basis"],"required":true,"pdf_field":""},{"help":"Select sum insured amount","type":"choice","label":"Sum Insured (Rs.)","options":["4,00,000","5,00,000"],"required":true,"pdf_field":""},{"help":"Select if waiver of co-pay is opted","type":"yes-no","label":"Waiver of Co-pay opted","options":[],"required":false,"pdf_field":""},{"help":"Select coverage type","type":"choice","label":"Coverage opted","options":["Pre-existing HIV/AIDS","Pre-existing Disability","Pre-existing HIV/AIDS and Disability"],"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 of Insured, Nationality, Relationship with Insured, DOB (dd/mm/yyyy), Age, Gender (M/F), Height (cms), Weight (kgs), Occupation, Marital Status, ABHA Number","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Nominee for self must be Father, Mother, Son, Daughter, Spouse or Other","type":"text","label":"Name, DOB (dd/mm/yyyy), Age, Relation, Nominee, Appointee (If nominee is minor), If Nominee is 'Others' please specify the relationship and reason","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous/Existing Health Details of Insured","fields":[{"help":"","type":"yes-no","label":"Do you suffer from HIV/AIDS?","options":[],"required":true,"pdf_field":""},{"help":"Attach recent CD4 count certificate","type":"attachment","label":"If Yes, please enclose a recent certificate of your current CD4 count (within past 30 days)","options":[],"required":false,"pdf_field":""},{"help":"Enter current CD4 count","type":"number","label":"Current CD4 count","options":[],"required":false,"pdf_field":""},{"help":"If yes, specify when and how many times","type":"yes-no","label":"Has your CD4 Count gone below 400 in the past 4 years?","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you suffer from any disability as per the listed conditions mentioned below","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you suffer from any pre-existing illness other than Disability or HIV AIDS mentioned above?","options":[],"required":true,"pdf_field":""},{"help":"Provide illness details and duration","type":"text","label":"If Yes, please specify details and the no of years you are suffering","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous/Existing Health Insurance details","fields":[{"help":"Provide details of previous health insurance policies","type":"table","label":"Policy No. / Application No., Insurer Name, Period of Insurance (from – to), Sum Insured, Claims lodged during the preceding years","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Electronic Insurance Account Details Section","fields":[{"help":"Select one repository if e-Format chosen","type":"choice","label":"Choose your Insurance Repository","options":["NSDL Data Management Ltd.","CDSL Insurance Repository Ltd","Karvy Insurance Repository Ltd.","CAMS Repository Services Ltd"],"required":false,"pdf_field":""},{"help":"Enter e-Insurance Account number if available","type":"text","label":"I have e Insurance Account & the No.","options":[],"required":false,"pdf_field":""},{"help":"Enter CKYC number if available","type":"text","label":"My CKYC No. (Central Know Your Customer registry number) is (If available)","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you want to open e-IA account","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"Select payment mode","type":"choice","label":"Payment Mode","options":["Full Payment","Instalment Payment"],"required":true,"pdf_field":""},{"help":"Select payment method","type":"choice","label":"Payment Details","options":["Cash","Cheque","DD","Credit Card","Debit Card","UPI"],"required":true,"pdf_field":""},{"help":"Select who gave the cheque if applicable","type":"choice","label":"Cheque Given By","options":["Spouse","Father","Mother","Son/Daughter","Financer","Employer/Employee"],"required":false,"pdf_field":""},{"help":"Consent for ASBA payment","type":"checkbox","label":"BIMA ASBA Declaration (Applicable only in case Premium payment through online payment mode)","options":["I authorize debit from my bank account upon acceptance of this proposal"],"required":false,"pdf_field":""},{"help":"Provide transaction details for payment","type":"text","label":"Amount, Transaction No., Transaction Date, Bank Name, Branch","options":[],"required":false,"pdf_field":""},{"help":"Provide bank details for policy servicing","type":"text","label":"Bank Details: Name as per Bank Account, Name of the Bank, IFSC Code, Bank Account No, Account Type, Mobile No, Email Address","options":[],"required":false,"pdf_field":""},{"help":"Select preferred contact method","type":"choice","label":"In case of any Offer, you would prefer to be contacted by","options":["Phone","Email","WhatsApp"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"If applicable, intermediary signs","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"","type":"yes-no","label":"Any Physical deformity or handicap? Yes/No","options":[],"required":true,"pdf_field":""},{"help":"Attach Disability Certificate issued by Medical Board","type":"text","label":"If Yes, Please provide details","options":[],"required":false,"pdf_field":""},{"help":"If proposer is disabled, authorised representative fills","type":"text","label":"Name of Authorised Representative","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Authorised Representative","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer or authorised representative"},{"title":"Agent Details and Declaration","fields":[{"help":"Agent fills their details and signs","type":"text","label":"Agent/IMD Name, Agent/IMD Code, Agent/IMD Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"},{"title":"PEP Declaration and Consent","fields":[{"help":"Politically Exposed Persons declaration","type":"yes-no","label":"Are you or any of the proposal applicants a PEP or a close relative of PEP?","options":[],"required":false,"pdf_field":""},{"help":"Provide details if PEP","type":"text","label":"If yes, please share the details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Persons with Disability and Persons with HIV/AIDS seeking health insurance coverage","attachments":["Recent certificate of current CD4 count (within past 30 days) if HIV/AIDS positive","Disability certificate mentioning percentage of disability wherever applicable"],"declarations":["The statements made in the form are true and complete to the best of the proposer's knowledge.","The policy will come into force only after full receipt of premium.","Notify in writing any change in occupation or health after submission but before acceptance.","Consent to company seeking medical and employer information for underwriting and claims.","Consent to share proposal and medical records with reinsurers, TPAs, government and regulatory authorities.","Awareness of premium loading for habits and diseases declared.","Agreement to keep KYC details of all insured members and provide beneficiary details when required.","Agent declaration that form contents were explained to proposer in vernacular language if needed.","Declaration that premium is paid from legally acquired sources.","Consent to verify identity/address proof through CERSAI or NSDL Portal for KYC verification.","Consent to share personal information with group companies and others as per privacy policies."],"dropped_labels":14},"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/2192-proposal-form"}