{"id":2439,"title":"PROPOSAL FORM Aapke Liye- Himachal Pradesh","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/aapke-liye/aapke-liye-himachal-pradesh/Aapke_Liye-Himachal_Pradesh_Digital_PF.pdf","sha256":"cea1f37b763298560d77eb2dc44dfcd3a33871cba1d10749ea223f14547825d3","pages":5,"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 Aapke Liye- Himachal Pradesh insurance policy.","notes":["Answer all questions in BLOCK letters.","Provide all information fully and accurately.","Use last 4 digits only for Aadhaar number.","Nominee for primary insured must be a close relative or specify reason if 'Others'.","Optional covers once opted cannot be opted out at renewal except accidental death cover.","Submission of proposal or payment does not oblige the company to issue policy.","Signature/thumb impression required on declaration.","Existing customers can confirm no change in KYC details.","Provide ABHA number if registered under Ayushmaan Bharat Yojana.","Use original and accurate details for all fields."],"title":"PROPOSAL FORM Aapke Liye- Himachal Pradesh","submit":{"to":"Bajaj Insurance House, Airport Road, Yerawada, Pune - 411006","how":"post or as per company instructions","address":"Bajaj Insurance House, Airport Road, Yerawada, Pune - 411006"},"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":"Title"},{"help":"If existing customer, provide policy number","type":"text","label":"The Policy No.","options":[],"required":false,"pdf_field":"Policy No OG"},{"help":"Provide 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":["Yes"],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":"Gender.0"},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":"DOB FROM"},{"help":"Enter your PAN number","type":"text","label":"Pan No.","options":[],"required":false,"pdf_field":"Pan No"},{"help":"Tick if you want credit score discount","type":"checkbox","label":"Do you wish to avail credit score discount if yes please provide below consent CIBIL Discount.","options":["Yes"],"required":false,"pdf_field":""},{"help":"Enter last 4 digits of Aadhaar number","type":"text","label":"UID/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":"text","label":"No. of children: Sons Daughters","options":[],"required":false,"pdf_field":""},{"help":"Select your occupation","type":"choice","label":"Occupation","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":true,"pdf_field":"Occupation.0"},{"help":"Select Yes or No","type":"yes-no","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana?","options":[],"required":false,"pdf_field":""},{"help":"Provide ABHA number if applicable","type":"text","label":"If Yes please share your Ayushmaan Bharat Health Account Number (ABHA) No. in below table","options":[],"required":false,"pdf_field":"ABHA Number101.0"}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Enter telephone number","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":"TelephoneNo"},{"help":"Enter mobile number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":"MobileNo"},{"help":"Enter alternate telephone number","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":"TelephoneNo1"},{"help":"Enter alternate mobile number","type":"phone","label":"Mobile","options":[],"required":false,"pdf_field":"MobileNo1"},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":true,"pdf_field":"Email"},{"help":"Enter alternate email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":"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 monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":"Monthly Income"},{"help":"Enter nationality","type":"text","label":"Nationality","options":[],"required":true,"pdf_field":"Nationality"},{"help":"Select policy term","type":"choice","label":"Policy Term","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Enter start date of insurance","type":"date","label":"Period of insurance From","options":[],"required":true,"pdf_field":"DOB FROM"},{"help":"Select policy type","type":"choice","label":"Policy type","options":["Individual","Floater"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee's full name","type":"text","label":"Name","options":[],"required":true,"pdf_field":"Nominee Name"},{"help":"Enter nominee's date of birth","type":"date","label":"DOB (dd/mm/yyyy)","options":[],"required":true,"pdf_field":"Nominee DOB"},{"help":"Enter nominee's age","type":"number","label":"Age","options":[],"required":true,"pdf_field":"Nominee Age"},{"help":"Enter relation of nominee to proposer","type":"text","label":"Relation","options":[],"required":true,"pdf_field":"Nominee Relation"},{"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":"If Nominee is Others please specify the relationship and reason"}],"filled_by":"proposer"},{"title":"Plan and Sum Insured Details","fields":[{"help":"Fill sum insured details for each member","type":"table","label":"Member Name, Sum Insured (Individual), Sum Insured (Floater)","options":[],"required":true,"pdf_field":"Member NameRow1"}],"filled_by":"proposer"},{"title":"Optional Covers","fields":[{"help":"Select sum insured reinstatement option","type":"choice","label":"Sum Insured Reinstatement (Once / Unlimited)","options":["Once","Unlimited"],"required":false,"pdf_field":""},{"help":"Select super cumulative bonus option","type":"choice","label":"Super Cumulative Bonus","options":["25% of SI max 100%","25% of SI max 200%","50% of SI max 100%"],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Procedure wise/ Disease wise sub-limit","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Cashless Discount","options":[],"required":false,"pdf_field":""},{"help":"Select copayment or aggregate deductible option","type":"choice","label":"Voluntary Copayment (5%, 10%, 15%, 20%) OR Voluntary Aggregate Deductible (10,000 to 3,00,000)","options":["5%","10%","15%","20%","10,000","20,000","30,000","40,000","50,000","1,00,000","2,00,000","3,00,000"],"required":false,"pdf_field":""},{"help":"Select yes or no (only at inception/renewal for proposer)","type":"yes-no","label":"Accidental Death Cover","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Status","fields":[{"help":"Answer yes or no and provide details if yes","type":"yes-no","label":"Has any proposal for life, critical illness or health insurance on your life or lives ever been postponed, declined or accepted on special terms? If yes, give details","options":[],"required":true,"pdf_field":""},{"help":"Answer yes or no for each insured member","type":"yes-no","label":"Has any of the persons to be insured suffer from or investigated for listed serious illnesses?","options":[],"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 (Cash, Cheque, DD, Credit Card, Debit Card, UPI)","options":["Cash","Cheque","DD","Credit Card","Debit Card","UPI"],"required":true,"pdf_field":""},{"help":"Select who gave the check if applicable","type":"choice","label":"Check- Given By","options":["Spouse","Father","Mother","Son/Daughter","Employer/Employee","Financier"],"required":false,"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 if applicable","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":"BIMA ASBA Declaration and Bank Details","fields":[{"help":"Select yes or no","type":"yes-no","label":"Do you want to open e-IA account","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account holder name","type":"text","label":"Name as per Bank Account","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No","options":[],"required":false,"pdf_field":""},{"help":"Enter account type","type":"text","label":"Account Type","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number linked to bank account","type":"phone","label":"Mobile No","options":[],"required":false,"pdf_field":""},{"help":"Enter email address linked to bank account","type":"email","label":"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":"Declarations and Consent","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Signature of agent or intermediary","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":""},{"help":"Signature of witness","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Health insurance proposal for Aapke Liye- Himachal Pradesh policy","attachments":[],"declarations":["The information provided is true and complete to the best of knowledge.","The policy liability starts only after acceptance and premium payment.","Notify the company in writing of any change in occupation or health before acceptance.","Consent to company seeking medical and insurance information for underwriting and claims.","Consent to share proposal and medical records with reinsurers and regulatory authorities.","Premium paid is from legally acquired sources and future premiums will be similarly paid.","Consent to verify identity/address through CERSAI or NSDL portals.","No inducement or rebate is allowed in insurance as per Insurance Act 1938 Section 41."],"dropped_labels":24},"pdf_fields":[{"name":"Scrutiny NoRow1","page":1,"type":"text","label":"Scrutiny No._Row_1"},{"name":"Receipt NoRow1","page":1,"type":"text","label":"Receipt No._Row_1"},{"name":"Policy NoRow1","page":1,"type":"text","label":"Policy No._Row_1"},{"name":"Loan Account NumberRow1","page":1,"type":"text","label":"Loan Account Number_Row_1"},{"name":"EmpLG CodeRow1","page":1,"type":"text","label":"Emp/LG Code_Row_1"},{"name":"IMD CodeRow1","page":1,"type":"text","label":"IMD Code_Row_1"},{"name":"Sub IMD CodeRow1","page":1,"type":"text","label":"Sub IMD Code_Row_1"},{"name":"IMD NameRow1","page":1,"type":"text","label":"IMD 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(cms)_(dd/mm"},{"name":"DOB1.8","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":"Age101.8","page":2,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.8","page":2,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.8","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.8","page":2,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Occupation.8","page":2,"type":"text","label":"Occupation_(dd/mm"},{"name":"Relation1.8","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Nationality101.8","page":2,"type":"text","label":"Nationality"},{"name":"ABHA Number101.8","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M3.7","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"DOB1.2","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":"Age101.9","page":2,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.9","page":2,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.9","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.9","page":2,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Occupation.2","page":2,"type":"text","label":"Occupation_(dd/mm"},{"name":"Relation1.9","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Nationality101.9","page":2,"type":"text","label":"Nationality"},{"name":"ABHA Number101.9","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M3.1.0","page":2,"type":"text","label":"Ht. 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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 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