{"id":2194,"title":"PROPOSAL FORM HEALTH CARE SUPREME","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/health-care-supreme/Health_care_supreme_PF.pdf","sha256":"62cb82c5d538e8728375f3d7818e67000ad85e06c25c64ca495e8ee2313d7e36","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a health insurance proposal form to be filled by the proposer (the person seeking insurance) to apply for the Health Care Supreme policy.","notes":["Answer all questions in BLOCK letters.","Provide all information fully and accurately.","Use last 4 digits of Aadhaar only.","Nominee for self must be Father, Mother, Son, Daughter, Spouse or Other with reason.","Personal Accident cover sum insured max Rs 5 lakhs for dependents.","If opting for portability, fill portability annexure.","Signatures required from proposer, intermediary, witness, and authorized representative if applicable.","Agent must declare having explained the form in vernacular language if needed.","Original bills and documents may be required for claims (not specified here).","Submission of proposal or payment does not oblige the company to issue policy."],"title":"PROPOSAL FORM HEALTH CARE SUPREME","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":"","type":"checkbox","label":"I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy","options":["I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter your date of birth in DD/MM/YYYY 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 number","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":"text","label":"No. of children: Sons Daughters","options":[],"required":false,"pdf_field":""},{"help":"Select your occupation or specify if Other","type":"choice","label":"Occupation","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":false,"pdf_field":""},{"help":"If yes, provide ABHA number in the table below","type":"yes-no","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana?","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Enter your permanent residential address","type":"text","label":"Permanent /Residential Address","options":[],"required":true,"pdf_field":""},{"help":"Enter your communication address","type":"text","label":"Communication Address (all communications will be sent to below)","options":[],"required":true,"pdf_field":""},{"help":"Enter telephone number","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"Select your highest educational qualification","type":"choice","label":"Educational Qualification","options":["Matriculate","Under Graduate","Graduate","Post Graduate","Professionally Qualified"],"required":false,"pdf_field":""},{"help":"Enter monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":""},{"help":"Enter your nationality","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":""},{"help":"Select policy period","type":"choice","label":"Policy Period","options":["1 year","2 years","3 years"],"required":true,"pdf_field":""},{"help":"Select policy type","type":"choice","label":"Policy Type","options":["Individual","Floater"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details Of Persons To Be Insured","fields":[{"help":"Fill details for each person to be insured","type":"table","label":"Member Name, Relationship with Proposer, DOB (dd/mm/yy), Age, Gender (M/F), Ht. (cms), Wt. (kgs), Occupation, ABHA Number","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Fill nominee details; nominee for self must be Father/Mother/Son/Daughter/Spouse/Other","type":"table","label":"Name, DOB (dd/mm/yyyy), Age, Relation, Nominee, Appointee (If nominee is minor)","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship and reason if nominee is 'Others'","type":"text","label":"If Nominee is 'Others' please specify the relationship and reason","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Add On Covers – Optional","fields":[{"help":"Tick if opting for this cover","type":"yes-no","label":"Ancillary Expenses Benefit Section","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick if opting for this cover","type":"yes-no","label":"Critical Illness","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick if opting for this cover","type":"yes-no","label":"Personal Accident","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick if opting for this cover","type":"yes-no","label":"Non-Medical Expenses Cover (Rider)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Fill sum insured for each add on cover per member","type":"table","label":"Member Name, Hospitalisation Section, Ancillary Expenses, Critical Illness, Personal Accident","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Other Health Insurance Details","fields":[{"help":"Fill details of other insurance policies if any","type":"table","label":"Do you have any other Health policy/policies, Personal Accident Policy/policies? Provide details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Answer yes or no","type":"yes-no","label":"5. Any other illness, impairment, disability or surgery not mentioned above?","options":["Yes","No"],"required":true,"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":"Provide transaction details for payment","type":"text","label":"Amount, Transaction No., Transaction Date, Bank Name, Branch","options":[],"required":false,"pdf_field":""},{"help":"Tick if you want to open e-IA account","type":"yes-no","label":"Do you want to open e-IA account","options":["Yes","No"],"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":""}],"filled_by":"proposer"},{"title":"Declaration and Signature","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Agent or intermediary signature","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":""},{"help":"Witness signature if applicable","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"Tick yes or no","type":"yes-no","label":"Any Physical deformity or handicap? Yes/No","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer or authorized representative"}],"deadlines":[],"applies_to":"Health Care Supreme insurance policy proposal","attachments":["Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability (if applicable)","Portability annexure (if opting for portability)"],"declarations":["The proposer declares that all information provided is true and complete to the best of their knowledge.","The policy will come into force only after full payment of the premium.","The proposer will notify any change in occupation or health after submission and before acceptance.","The company may seek medical information from doctors, hospitals, employers, or insurers for underwriting and claims.","Consent is given to collect and share personal and medical information from ABHA for underwriting and claims.","Agent declares having explained the form contents and consequences of untrue statements or non-disclosure.","Premiums are paid from legally acquired sources and subsequent premiums will be paid similarly.","Consent is given for KYC verification through CERSAI or NSDL portals.","No rebate or inducement is allowed as per Insurance Act 1938 Section 41."],"dropped_labels":27},"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/2194-proposal-form-health-care-supreme"}