{"id":2196,"title":"PROPOSAL FORM SILVER HEALTH","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/digital-pf/Silver-health-pf-digital.pdf","sha256":"5a0455866b06d9ea522785d0f909ac245c29254b33c3234ae565e83c341ddfff","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is a health insurance proposal form to be filled by the proposer (policyholder) to apply for the Silver Health insurance policy.","notes":["Please answer all questions in BLOCK letters.","The liability of the company starts only after acceptance of proposal and premium payment.","Use original documents and provide accurate information.","Nominee for self must be a close family member (Father, Mother, Son, Daughter, Spouse, Other).","If proposer is disabled, authorized representative must sign the form.","This form and particulars must be explained in vernacular language if proposer does not understand English.","No rebate of commission or premium is allowed as per Insurance Act 1938 Section 41.","Submission of proposal or payment does not oblige the company to issue a policy."],"title":"PROPOSAL FORM SILVER HEALTH","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter your full name with title in block letters","type":"text","label":"Full Name: Title First Name Middle Name Surname","options":[],"required":true,"pdf_field":"Title, First Name, Middle Name, Surname"},{"help":"Enter existing policy number if any","type":"text","label":"the Policy No.: OG","options":[],"required":false,"pdf_field":"Policy No OG"},{"help":"Enter PID number if existing customer","type":"text","label":"Existing Customer (PID) No.","options":[],"required":false,"pdf_field":"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":["I hereby confirm"],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":"DOB"},{"help":"Enter your PAN number","type":"text","label":"Pan No.","options":[],"required":false,"pdf_field":"Pan No"},{"help":"Enter last 4 digits of Aadhaar number","type":"text","label":"Aadhaar No. Enter last 4 digits only","options":[],"required":false,"pdf_field":"Aadhaar No"},{"help":"Select your marital status","type":"choice","label":"Marital Status","options":["Married","Single","Divorced","Widowed"],"required":false,"pdf_field":""},{"help":"Enter number of sons and daughters","type":"number","label":"No. of children: Sons Daughters","options":[],"required":false,"pdf_field":"Son, Daughters"},{"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 communication address details","type":"text","label":"Communication Address (all communications will be sent to below): House No., House Name, Landmark/Locality, Road/Area Name, City/District, State, Pin Code, Telephone, Mobile, Email","options":[],"required":true,"pdf_field":"House No1, House Name_2, LandmarkLocality_2, RoadArea Name, CityDistrict_2, State_2, Pin Code1, TelephoneNo1, MobileNo1, Email_2"}],"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 your monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":"Monthly Income"},{"help":"Enter your nationality","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":"Nationality"},{"help":"Select the policy term","type":"choice","label":"Policy Term","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":""},{"help":"Select plan option","type":"choice","label":"Plan opted","options":["Plan A","Plan B"],"required":true,"pdf_field":"Plan Option"},{"help":"Select if applicable; discounts apply as described","type":"text","label":"Room Rent Capping Options","options":[],"required":false,"pdf_field":""},{"help":"Select if you want waiver","type":"yes-no","label":"Waiver of Non-network co-payment","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if you want Health Prime Rider","type":"yes-no","label":"Health Prime Rider","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If Yes, furnish details in attached annexure","type":"yes-no","label":"Respect Rider","options":["Yes","No"],"required":false,"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), Individual Sum Insured, Floater Sum Insured, Non-Medical Expense Rider, ABHA Number","options":[],"required":true,"pdf_field":"M1.1, Relation1.0.0, DOB1.0.0, Age101.0.0, Gender1.1.0, Ht.0.0, Wt.0.0, Premium.0, Floater Sum Insured, Non-Medical Expense Rider, ABHA Number101.0"},{"help":"Consent for accessing ABHA data","type":"checkbox","label":"ABHA Declaration","options":["I/We provide my/our consent to access my/our medical and personal records for underwriting and claims"],"required":false,"pdf_field":""},{"help":"Fill nominee details; nominee for self must be close family","type":"text","label":"Nominee Details: 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":"NomineeName, Nominee DOB, AgeNominee, RelationNominee, Appointee Name, Appointee DOB, AgeAppointee, RelationAppointee, If Nominee is Others please specify the relationship and reason"}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Has any of the persons to be insured suffer from/or investigated for any of the listed diseases?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has any proposal for life, critical illness or health insurance on your life ever been postponed, declined or accepted on special terms?","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Details and Payment","fields":[{"help":"Select payment mode","type":"choice","label":"Payment Mode","options":["Full Payment","Instalment Payment"],"required":true,"pdf_field":""},{"help":"Select payment mode","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 online payment debit","type":"checkbox","label":"BIMA ASBA Declaration","options":["Consent to debit bank account upon acceptance"],"required":false,"pdf_field":""},{"help":"Provide payment transaction details","type":"text","label":"Amount, Transaction No, Transaction Date, Bank Name, Branch","options":[],"required":false,"pdf_field":"Amount, Transaction No, TransationDate, Bank Name, Branch"},{"help":"Provide bank details for premium refund or 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":"Name of the Bank, IFSC Code, Bank Account No, Account Type, Mobile No, Email Address"}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Declare any physical deformity or handicap and provide certificate if Yes","type":"yes-no","label":"Disability Declaration","options":["Yes","No"],"required":false,"pdf_field":"Disability Certificate"}],"filled_by":"proposer and agent"}],"deadlines":[],"applies_to":"Silver Health insurance policy proposal","attachments":["Disability Certificate (if applicable)","Annexure for Respect Rider details (if opted)"],"declarations":["The information provided is true and complete to the best of my knowledge.","The policy will be effective only after premium payment and acceptance by the company.","I will notify any change in occupation or health before risk acceptance.","I consent to the company seeking medical and insurance information for underwriting and claims.","I consent to the company accessing and sharing my ABHA data for underwriting and claims.","Agent declares having explained the form contents in vernacular language if required.","Non-disclosure or untrue statements may lead to policy cancellation and forfeiture of premiums.","Premiums are paid from legally acquired sources.","Consent is given for KYC verification and data sharing as applicable."],"dropped_labels":20},"pdf_fields":[{"name":"Scrutiny No","page":1,"type":"text","label":"Scrutiny No._Row_1"},{"name":"Receipt No","page":1,"type":"text","label":"Receipt No._Row_1"},{"name":"Policy No","page":1,"type":"text","label":"Policy No._Row_1"},{"name":"Loan Account No","page":1,"type":"text","label":"Loan Account Number_Row_1"},{"name":"EmpLG No","page":1,"type":"text","label":"Emp/LG Code_Row_1"},{"name":"IMD Code","page":1,"type":"text","label":"IMD Code_Row_1"},{"name":"Sub IMD Code","page":1,"type":"text","label":"Sub IMD Code_Row_1"},{"name":"IMD NameRow1","page":1,"type":"text","label":"IMD Name_Row_1"},{"name":"MobileNO","page":1,"type":"text","label":"Mobile_Row_1"},{"name":"Title","page":1,"type":"text","label":"First Name"},{"name":"First Name","page":1,"type":"text","label":"First Name"},{"name":"Middle Name","page":1,"type":"text","label":"First Name"},{"name":"Surname","page":1,"type":"text","label":"First Name"},{"name":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Policy No OG","page":1,"type":"text","label":"a. The Policy No.: OG"},{"name":"PID NO","page":1,"type":"text","label":"b. Existing Customer (PID) No"},{"name":"Group No2","page":1,"type":"radiobutton"},{"name":"Group No3","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No3","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No3","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"DOB","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Pan No","page":1,"type":"text","label":"First Name"},{"name":"Aadhaar No","page":1,"type":"text","label":"Enter last 4 digits only"},{"name":"Employee Code","page":1,"type":"text","label":"7.Bajaj Allianz Employee Code , if Proposer is BAGIC/BALIC  Employee"},{"name":"Group No4","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1","Choice1"]},{"name":"Group No4","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1","Choice1"]},{"name":"Group No4","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1","Choice1"]},{"name":"Group No4","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1","Choice1"]},{"name":"Son","page":1,"type":"text","label":"Mobile"},{"name":"Daughters","page":1,"type":"text","label":"Mobile"},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group 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Name"},{"name":"LandmarkLocality","page":1,"type":"text","label":"Landmark/Locality"},{"name":"LandmarkLocality_2","page":1,"type":"text","label":"Landmark/Locality"},{"name":"RoadArea Name","page":1,"type":"text","label":"Road/Area Name"},{"name":"CityDistrict_2","page":1,"type":"text","label":"City/District"},{"name":"CityDistrict","page":1,"type":"text","label":"City/District"},{"name":"CityDistrict_2","page":1,"type":"text","label":"City/District"},{"name":"State","page":1,"type":"text","label":"State"},{"name":"State_2","page":1,"type":"text","label":"State"},{"name":"Pin Code","page":1,"type":"text","label":"Pin Code:"},{"name":"Pin Code1","page":1,"type":"text","label":"Pin Code:"},{"name":"TelephoneNo","page":1,"type":"text","label":"Telephone"},{"name":"MobileNo","page":1,"type":"text","label":"Mobile"},{"name":"TelephoneNo1","page":1,"type":"text","label":"Telephone"},{"name":"MobileNo1","page":1,"type":"text","label":"Mobile"},{"name":"Email","page":1,"type":"text","label":"Email"},{"name":"Email_2","page":1,"type":"text","label":"Email"},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Monthly Income","page":1,"type":"text","label":"undefined"},{"name":"Nationality","page":1,"type":"text","label":"undefined"},{"name":"Group No9","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No9","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No9","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"DOB FROM","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"DOB TO","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Group No901","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No901","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No902","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No902","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No9022","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No9022","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No90222","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No90222","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No903","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No903","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Plan Option","page":1,"type":"text","label":"undefined"},{"name":"Group No902222","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No902222","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"M1.1","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.0.0","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.0.0","page":2,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.0.0","page":2,"type":"text","label":"Age_(dd/mm"},{"name":"Gender1.1.0","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Ht.0.0","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0.0","page":2,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Premium.0","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Floater Sum Insured","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Group NoS1001","page":2,"type":"radiobutton","options":["Choice6","Choice6"]},{"name":"Group NoS1001","page":2,"type":"radiobutton","options":["Choice6","Choice6"]},{"name":"ABHA Number101.0","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M1.4","page":2,"type":"text","label":"Ht. 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(cms)_(dd/mm"},{"name":"Relation1.2.0","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.3.0","page":2,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.3.0","page":2,"type":"text","label":"Age_(dd/mm"},{"name":"Gender1.4.0","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Ht.0.3","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0.3","page":2,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Premium.3","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Group NoS1004","page":2,"type":"radiobutton","options":["Choice6","Choice6"]},{"name":"Group NoS1004","page":2,"type":"radiobutton","options":["Choice6","Choice6"]},{"name":"ABHA Number101.4","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M1.3","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.4.0","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.4.0","page":2,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.4.0","page":2,"type":"text","label":"Age_(dd/mm"},{"name":"Gender1.5.0","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Ht.0.4","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0.4","page":2,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Premium.4","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Group NoS1005","page":2,"type":"radiobutton","options":["Choice6","Choice6"]},{"name":"Group NoS1005","page":2,"type":"radiobutton","options":["Choice6","Choice6"]},{"name":"ABHA Number101.1","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Group No9022228888","page":2,"type":"radiobutton"},{"name":"NomineeName","page":2,"type":"text","label":"Name_Nominee*"},{"name":"Nominee DOB","page":2,"type":"text","label":"DOB (dd/mm/yyyy)_Nominee*"},{"name":"AgeNominee","page":2,"type":"text","label":"Age_Nominee*"},{"name":"RelationNominee","page":2,"type":"text","label":"Relation_Nominee*"},{"name":"Appointee Name","page":2,"type":"text","label":"Name_Appointee (If nominee is minor)"},{"name":"Appointee DOB","page":2,"type":"text","label":"DOB (dd/mm/yyyy)_Appointee (If nominee is minor)"},{"name":"AgeAppointee","page":2,"type":"text","label":"Age_Appointee (If nominee is minor)"},{"name":"RelationAppointee","page":2,"type":"text","label":"Relation_Appointee (If nominee is minor)"},{"name":"If Nominee is Others please specify the relationship and reason","page":2,"type":"text","label":"If Nominee is \"Others\" please specify the relationship and reason"},{"name":"Group NoS2","page":2,"type":"radiobutton","options":["Choice6","Choice6"]},{"name":"Group NoS2","page":2,"type":"radiobutton","options":["Choice6","Choice6"]},{"name":"Group NoS3","page":2,"type":"radiobutton","options":["Choice6","Choice6"]},{"name":"Group NoS3","page":2,"type":"radiobutton","options":["Choice6","Choice6"]},{"name":"Name of the personRow1","page":2,"type":"text","label":"Name of the person_Row_1"},{"name":"Name of the Illness injury suffered  suffering in the pastRow1","page":2,"type":"text","label":"Name of the Illness /injury suffered / suffering in the past_Row_1"},{"name":"Treatment detailsRow1","page":2,"type":"text","label":"Treatment details_Row_1"},{"name":"Date first treatedRow1","page":2,"type":"text","label":"Date first treated_Row_1"},{"name":"Current Status of the Illness DiseasesInjuryRow1","page":2,"type":"text","label":"Current Status of the Illness/ Diseases/Injury_Row_1"},{"name":"Name of the personRow2","page":2,"type":"text","label":"Name of the person_Row_2"},{"name":"Name of the Illness injury suffered  suffering in the pastRow2","page":2,"type":"text","label":"Name of the Illness /injury suffered / suffering in the past_Row_2"},{"name":"Treatment detailsRow2","page":2,"type":"text","label":"Treatment details_Row_2"},{"name":"Date first treatedRow2","page":2,"type":"text","label":"Date first treated_Row_2"},{"name":"Current Status of the Illness DiseasesInjuryRow2","page":2,"type":"text","label":"Current Status of the Illness/ Diseases/Injury_Row_2"},{"name":"Name of the personRow3","page":2,"type":"text","label":"Name of the person_Row_3"},{"name":"Name of the Illness injury suffered  suffering in the 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