{"id":2199,"title":"HOSPITAL CASH DAILY ALLOWANCE POLICY PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/digital-pf/Hospital-cash-daily-allowance-pf-final.pdf","sha256":"6cbeebb32cf76eed89afc86b442c32e42b34f98655444b9760873576f654a18b","pages":4,"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 insurance details for underwriting.","notes":["Please answer all questions in BLOCK letters.","The liability of the company starts only after acceptance of the proposal and premium payment.","Provide all information fully and accurately as it forms the basis of the policy.","Use original documents where required.","This form includes sections for proposer details, health history, payment, portability, and declarations.","For any queries, call Sales - 1800 209 0144 or Service - 1800 209 5858 (Toll Free)."],"title":"HOSPITAL CASH DAILY ALLOWANCE POLICY PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter your full name with Title, First Name, Middle Name, and Surname in block letters","type":"text","label":"1) Full Name:","options":[],"required":true,"pdf_field":"Title, First Name, Middle Name, Surname"},{"help":"Enter your house number","type":"text","label":"House No.","options":[],"required":null,"pdf_field":"House No"},{"help":"Enter your house name","type":"text","label":"House Name","options":[],"required":null,"pdf_field":"House"},{"help":"Enter landmark or locality near your residence","type":"text","label":"Landmark/Locality","options":[],"required":null,"pdf_field":"Landmark"},{"help":"Enter road or area name","type":"text","label":"Road/Area Name","options":[],"required":null,"pdf_field":"Area Name"},{"help":"Enter city or district","type":"text","label":"City/District","options":[],"required":null,"pdf_field":"CityDistrict"},{"help":"Enter state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":"Pin Code"},{"help":"Enter telephone number if available","type":"phone","label":"Tel.","options":[],"required":false,"pdf_field":"TelOffice.0"},{"help":"Enter mobile phone number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":"Mobile"},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":"EMail"},{"help":"Select your gender","type":"choice","label":"3) Gender:","options":["Male","Female","Other"],"required":true,"pdf_field":"Group4"},{"help":"Enter your date of birth in dd/mm/yyyy format","type":"date","label":"4) Date of Birth","options":[],"required":true,"pdf_field":"4 Date of Birth"},{"help":"Enter your PAN number","type":"text","label":"5) PAN No.","options":[],"required":false,"pdf_field":"5 PAN No"},{"help":"Enter your Aadhaar number","type":"text","label":"6) UID/Aadhaar no.:","options":[],"required":true,"pdf_field":"6 UIDAadhaar no"},{"help":"Enter employee code if applicable","type":"text","label":"7) Bajaj General Employee Code if Proposer is Bajaj General/Bajaj Life Employee","options":[],"required":false,"pdf_field":"7 Bajaj Allianz Employee Code if Proposer is BAGICBALIC Employee"},{"help":"Select your marital status","type":"choice","label":"8) Marital Status:","options":["Married","Single","Divorced","Widowed"],"required":true,"pdf_field":"Group1"},{"help":"Enter number of sons and daughters","type":"table","label":"9) No. of Children","options":[],"required":false,"pdf_field":"Sons, Daughters"},{"help":"Select your occupation or specify if Others","type":"choice","label":"10) Occupation","options":["Business","Salaried","Professional","Student","House Wife","Retired","Others"],"required":true,"pdf_field":"Group2"},{"help":"Fill address details as above for permanent/residential address","type":"text","label":"11 a) Permanent / Residential Address","options":[],"required":true,"pdf_field":"House No_2, House_2, Landmark_2, Area Name_2, CityDistrict_2, Pin Code_2, TelOffice.1, Mobile Number"},{"help":"Enter correspondence address and email","type":"text","label":"11 b) Correspondence Address: (All the communications will be sent to the below address)","options":[],"required":true,"pdf_field":"EMail"},{"help":"Select your highest educational qualification","type":"choice","label":"12) Educational Qualification:","options":["Matriculate","Under Graduate","Graduate","Post Graduate","Professionally Qualified"],"required":false,"pdf_field":"Group5"},{"help":"Select your family monthly income range","type":"choice","label":"13) Family Monthly Income:","options":["Up to Rs. 20,000","Rs. 20,001 to Rs. 50,000","Rs. 50,001 to Rs. 1 lakh","Above Rs. 1 lakh"],"required":false,"pdf_field":"Group6"},{"help":"Select preferred contact method","type":"choice","label":"14) In case of any Offer, you would prefer to be contacted by:","options":["Phone","Email"],"required":false,"pdf_field":"Group7"},{"help":"Enter your nationality","type":"text","label":"15) Nationality","options":[],"required":true,"pdf_field":"15Nationality"},{"help":"Select desired policy period","type":"choice","label":"16) Policy Period:","options":["1 year","2 years","3 years"],"required":true,"pdf_field":"Group005"},{"help":"Select payment mode","type":"choice","label":"17) Payment mode:","options":["Full Payment","Installment Payment"],"required":true,"pdf_field":"Group A1.0"},{"help":"Select installment frequency if installment payment chosen","type":"choice","label":"If opted Installment payment mode","options":["Monthly","Quarterly","Half yearly"],"required":false,"pdf_field":"Group A1.1"},{"help":"Fill details for each person: Sr No, Name, DOB (dd/mm/yy), Age, Gender (M/F), Height (Cms), Weight (Kgs), Occupation, Relation, Nominee, Premium, Coverage opted (500/1000/2000/2500 Rs. per day), Relationship of Nominee, Net Monthly Income","type":"table","label":"18) Details of the persons to be insured","options":[],"required":true,"pdf_field":"Text6.0.0.0.0.0 to Text6.8.0.1.0.4 and related fields"},{"help":"Enter start date of insurance period","type":"date","label":"19) Period of Insurance: From","options":[],"required":true,"pdf_field":"Period of insurance.0"},{"help":"Enter end date of insurance period","type":"date","label":"To","options":[],"required":true,"pdf_field":"Period of insurance.1"},{"help":"Select Yes or No and provide details if Yes","type":"text","label":"20) Do you smoke cigarettes or consume tobacco (chewing paste) / alcohol, nicotine or marijuana in any form? Please give duration and daily consumption","options":["Yes","No"],"required":true,"pdf_field":"Group30"},{"help":"Indicate if you are an existing customer and provide policy number","type":"text","label":"2) Are you an existing Bajaj General Customer: Yes / No If yes, please mention the Policy No:","options":[],"required":false,"pdf_field":""},{"help":"Provide ABHA Number (14 digits) if applicable","type":"table","label":"10 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":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health and Family Medical History","fields":[{"help":"Select Yes or No and provide details in the table if Yes","type":"choice","label":"21) Has any of the persons to be insured suffer from/or investigated for any of the following? Disorder of the heart, or circulatory system, chest pain, high blood pressure, stroke, asthma any respiratory conditions, cancer tumor lump of any kind, diabetes, hepatitis, disorder of urinary tract or kidneys, blood disorder, any mental or psychiatric conditions, any disease of brain or nervous system, fits (epilepsy) slipped disc, backache, any congenital/ birth defects/ urinary diseases, AIDS or positive HIV, If yes, indicate in the table given below.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No and provide member name, relationship, disease name, and age at illness","type":"choice","label":"22) Have any of your immediate family members (father, mother, brother or sister) have/ had diabetes, hypertension, cancer, heart attack, or stroke and at what age? If yes, was it before age 60 years or after 60 years?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No and specify months if Yes","type":"choice","label":"23) Please confirm, if any of the person to be insured is pregnant (For Females Only). If yes, please state how many months?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No and provide details if Yes","type":"choice","label":"24) Do you or any of the family members to be covered have/had any health complaints/met with any accident in the past 4 years and prior to 4 years and have been taking treatment, regular medication (self/ prescribed) or planned for any treatment / surgery / hospitalization? If yes, share details in the table.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"25) Has any proposal for life, critical illness or health related insurance on your life or lives ever been postponed, declined or accepted on special terms? If yes, give details","options":[],"required":false,"pdf_field":""},{"help":"Provide family doctor's details","type":"text","label":"26) Family Doctor Details: Name, Qualification, Address, Mobile, Reg No.","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select payment mode","type":"choice","label":"27) Payment Details","options":["Cash","Cheque","DD","Credit Card","Debit Card"],"required":true,"pdf_field":""},{"help":"Enter payment amount","type":"amount","label":"Amount","options":[],"required":true,"pdf_field":""},{"help":"Enter transaction number if applicable","type":"text","label":"Transaction No.","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction date","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name if applicable","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Enter bank branch if applicable","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Portability Form","fields":[{"help":"Enter name of policyholder or insured","type":"text","label":"1) Name of the Policyholder / insured (s)","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth or age","type":"text","label":"2) Date of Birth / Age","options":[],"required":false,"pdf_field":""},{"help":"Enter address","type":"text","label":"3) Address of policyholder /insured","options":[],"required":false,"pdf_field":""},{"help":"Provide details of existing insurance","type":"text","label":"4) Details of existing insurer: i. Name of the product, ii. Sum Insured, iii. Cumulative Bonus, iv. Add ons/Riders taken, v. Policy Number","options":[],"required":false,"pdf_field":""},{"help":"Provide details of proposed insurance","type":"text","label":"5) Details of the proposed insurance: i. Name of the product proposed/intended to take, ii. Sum insured proposed, iii. 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