{"id":2198,"title":"PROPOSAL FORM HOSPITAL CASH DAILY ALLOWANCE","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/hospital-cash-daily-allowance/Hospital_cash_daily_allowance-pf.pdf","sha256":"5075548e09b0603485155b3dbfd3e5c7e3867cef800e5b562827c987f90e80fd","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for a Hospital Cash Daily Allowance insurance policy with Bajaj General Insurance. The proposer fills it to provide personal, health, and nominee details for underwriting.","notes":["Answer all questions in BLOCK letters.","Use original and accurate information; non-disclosure may void the policy.","Nominee for self must be a close family member (Father, Mother, Son, Daughter, Spouse, Other).","If the proposer is disabled, an authorized representative may sign the form.","The form must be signed by the proposer and agent where applicable.","The proposal does not bind the company to issue a policy; acceptance is at company's discretion.","Use the ABHA number if registered under Ayushmaan Bharat Yojana.","Provide complete and accurate bank details for policy servicing.","If the form is explained in vernacular language, signatures of proposer and intermediary are required."],"title":"PROPOSAL FORM HOSPITAL CASH DAILY ALLOWANCE","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":"Enter existing policy number if any","type":"text","label":"the Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Enter PID if existing customer","type":"text","label":"Existing Customer (PID) No.","options":[],"required":false,"pdf_field":""},{"help":"Tick if no change in KYC details","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":"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":""},{"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":"Select 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":""},{"help":"Select occupation or specify if Other","type":"choice","label":"Occupation","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":false,"pdf_field":""},{"help":"Select Yes or No","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":""},{"help":"Provide ABHA number if applicable","type":"text","label":"If Yes please share your Ayushmaan Bharat Health Account Number (ABHA) in below table","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Fill complete communication address and contact 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":""}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"Select 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 nationality","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":""},{"help":"Select policy term","type":"choice","label":"Policy Term","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details Of Persons To Be Insured","fields":[{"help":"Fill details for each person to be insured in the table","type":"table","label":"Member Name, Relationship with Proposer, DOB (dd/mm/yy), Age, Gender (M/F), Height (cms), Weight (kgs), Occupation, Net Monthly Income, Coverage opted, ABHA Number, 30 days/60 days, 500/1000/2000/2500 Rs. per day","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Fill nominee details; nominee for self must be close family member","type":"table","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":"Health Questionnaire","fields":[{"help":"Provide family doctor details if available","type":"text","label":"g. Family Doctor Details: Name, Qualification, Registration No., Mobile No., Address","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 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":"Tick to authorize ASBA payment if applicable","type":"checkbox","label":"BIMA ASBA Declaration","options":["I authorize BIMA ASBA facility for payment"],"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":"Select Yes or No","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","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Intermediary to sign","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":""},{"help":"Declare any disability and provide certificate details","type":"text","label":"Disability Declaration: Any Physical deformity or handicap? If Yes, provide details","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent Details and Declaration","fields":[{"help":"Agent to fill and sign","type":"text","label":"Agent/IMD Name, Agent/IMD Code, Agent/IMD Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"}],"deadlines":[],"applies_to":"Hospital Cash Daily Allowance insurance proposal","attachments":["Disability Certificate issued by the Medical Board appointed by the Government (if applicable)"],"declarations":["The information provided is true and complete to the best of the proposer's knowledge.","The policy will be effective only after premium receipt and acceptance by the company.","The proposer will notify any changes in occupation or health before risk acceptance.","The company may seek medical and personal information for underwriting and claims.","Consent is given to use ABHA data for underwriting and claims settlement.","Agent declares having explained the form contents and consequences of non-disclosure.","Premiums are paid from legally acquired sources.","Consent is given for KYC verification through authorized portals.","Consent is given to share personal data with group companies and third parties for services."],"dropped_labels":22},"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/2198-proposal-form-hospital-cash-daily-allowance"}