{"id":2444,"title":"PROPOSAL FORM Aapke Liye- Andaman & Nicobar Islands","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-andaman-nicobar-islands/AapKe_Liye-Andaman_Nicobar_Islands_Digital_PF.pdf","sha256":"6663cd7e19f310803f57d892de1387923025c0fa17ab41facb916168539d2100","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- Andaman & Nicobar Islands health insurance policy.","notes":["Answer all questions in BLOCK letters.","Liability of the company starts only after proposal acceptance and premium payment.","Provide all information fully and accurately.","Use original documents and provide additional information if relevant.","Once optional covers are opted, cannot opt out at subsequent renewals.","Nominee for primary insured must be a close family member or specify relationship if 'Others'.","Submission of proposal or payment does not oblige the company to issue a policy.","Signature/thumb impression required on the form.","Use the form's own labels and fields for accurate filling."],"title":"PROPOSAL FORM Aapke Liye- Andaman & Nicobar Islands","submit":{"to":"Bajaj General Insurance Limited","how":"","address":"Bajaj Insurance House, Airport Road, Yerawada, Pune - 411006"},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Select your title","type":"choice","label":"Title","options":[],"required":true,"pdf_field":"Title"},{"help":"Enter your first name in BLOCK letters","type":"text","label":"First Name","options":[],"required":true,"pdf_field":"First Name"},{"help":"Enter your middle name if any","type":"text","label":"Middle Name","options":[],"required":false,"pdf_field":"Middle Name"},{"help":"Enter your surname in BLOCK letters","type":"text","label":"Surname","options":[],"required":true,"pdf_field":"Surname"},{"help":"Enter existing policy number if any","type":"text","label":"The Policy No.","options":[],"required":false,"pdf_field":"Policy No OG"},{"help":"Enter your existing customer PID number if applicable","type":"text","label":"Existing Customer (PID) No.","options":[],"required":false,"pdf_field":"PID NO"},{"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":"Gender.0"},{"help":"Enter your date of birth (DD/MM/YYYY)","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 consent to 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 your 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","type":"number","label":"No. of children: Sons","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":"choice","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter ABHA number if registered","type":"text","label":"If Yes please share your Ayushmaan Bharat Health Account Number (ABHA) No.","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":false,"pdf_field":"MobileNo"},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":"Email"}],"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","options":[],"required":false,"pdf_field":"Monthly Income"},{"help":"Enter your nationality","type":"text","label":"Nationality","options":[],"required":false,"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 policy start date (DD/MM/YYYY)","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":"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":"Optional Covers","fields":[{"help":"Select sum insured reinstatement option","type":"choice","label":"Sum Insured Reinstatement","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 voluntary copayment percentage","type":"choice","label":"Voluntary Copayment","options":["5%","10%","15%","20%"],"required":false,"pdf_field":""},{"help":"Select voluntary aggregate deductible amount","type":"choice","label":"Voluntary Aggregate Deductible","options":["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 if you want accidental death cover (only proposer)","type":"choice","label":"Accidental Death Cover","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Loyalty Discount","fields":[{"help":"Select Yes or No","type":"choice","label":"Do you have Motor, Health/ Personal Accident, Home, Cyber and Pet Insurance with a premium more than INR 2500?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter policy details for other insurances held","type":"table","label":"If yes please provide the details in below table: Policy number, Policy period, LOB for members 1 to 10","options":[],"required":false,"pdf_field":"Policy numberMember 1"},{"help":"Select health prime rider option","type":"checkbox","label":"Health Prime Rider","options":["Yes","No","Individual Option 3","Floater Option 1"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Status","fields":[{"help":"Select Yes or No for each insured","type":"checkbox","label":"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":false,"pdf_field":""},{"help":"Select Yes or No and provide details if Yes","type":"checkbox","label":"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":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No for each insured","type":"checkbox","label":"Has any of the persons to be insured suffer from/or investigated for any of the following disorders: heart, circulatory system, chest pain, high blood pressure, stroke, asthma, cancer, diabetes, hepatitis, urinary tract, blood disorder, mental or psychiatric conditions, brain or nervous system diseases, fits, vertebral column disorder, congenital defects, AIDS or HIV?","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 - 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","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","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Enter bank branch","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":"choice","label":"Do you want to open e-IA account","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter name as per bank account","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","type":"phone","label":"Mobile No","options":[],"required":false,"pdf_field":""},{"help":"Enter email address linked to bank","type":"email","label":"Email Address","options":[],"required":false,"pdf_field":""},{"help":"Select preferred contact mode","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 put 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":"Enter witness name","type":"text","label":"Name of Witness","options":[],"required":false,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"PEP and KYC Consent","fields":[{"help":"Select Yes or No","type":"choice","label":"Are you or any of the proposal applicants a PEP or a close relative of PEP?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details if Yes","type":"text","label":"If yes, please share the details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Health insurance proposal for Aapke Liye- Andaman & Nicobar Islands policy","attachments":[],"declarations":["The information provided is true and complete to the best of knowledge.","The policy will commence only after acceptance and premium payment.","Notify any change in occupation or health after proposal submission before acceptance.","Consent to company seeking medical information from doctors, hospitals, employers for underwriting and claims.","Consent to share proposal and medical records with reinsurers and regulatory authorities.","No person shall offer or accept rebates except as allowed by insurer's published prospectus.","Premium paid is from legally acquired sources.","Consent to KYC verification through CERSAI or NSDL portals.","Consent to share personal data with group companies for products and services."],"dropped_labels":41},"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 Name_Row_1"},{"name":"Mobile NoRow1","page":1,"type":"text","label":"Mobile No_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":"Policy No OG","page":1,"type":"text","label":"a. The Policy No.: OG"},{"name":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"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"},{"name":"Group No3","page":1,"type":"radiobutton"},{"name":"Group No3","page":1,"type":"radiobutton"},{"name":"date","page":1,"type":"text","label":"Enter last 4 digits only"},{"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":"C.No","page":1,"type":"text","label":"House Name"},{"name":"D.No","page":1,"type":"text","label":"House Name"},{"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 No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group 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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":"Group No0011","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No0011","page":1,"type":"radiobutton","options":["Choice3","Choice3"]},{"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":"M1","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"DOB1.0","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","page":2,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.0","page":2,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.0","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0","page":2,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Occupation.0","page":2,"type":"text","label":"Occupation_(dd/mm"},{"name":"Relation1.0","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Nationality101.0","page":2,"type":"text","label":"Nationality"},{"name":"ABHA Number101.0","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M2","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"DOB1.1","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":"Age101.1","page":2,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.1","page":2,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.1","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.1","page":2,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Occupation.1","page":2,"type":"text","label":"Occupation_(dd/mm"},{"name":"Relation1.1","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Nationality101.1","page":2,"type":"text","label":"Nationality"},{"name":"ABHA Number101.1","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M3.2","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"DOB1.4","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","page":2,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.4","page":2,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.4","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.4","page":2,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Occupation.4","page":2,"type":"text","label":"Occupation_(dd/mm"},{"name":"Relation1.4","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Nationality101.4","page":2,"type":"text","label":"Nationality"},{"name":"ABHA Number101.4","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M3.3","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"DOB1.5","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":"Age101.5","page":2,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.5","page":2,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.5","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.5","page":2,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Occupation.5","page":2,"type":"text","label":"Occupation_(dd/mm"},{"name":"Relation1.5","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Nationality101.5","page":2,"type":"text","label":"Nationality"},{"name":"ABHA Number101.5","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M3.4","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"DOB1.6","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":"Age101.6","page":2,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.6","page":2,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.6","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.6","page":2,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Occupation.6","page":2,"type":"text","label":"Occupation_(dd/mm"},{"name":"Relation1.6","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Nationality101.6","page":2,"type":"text","label":"Nationality"},{"name":"ABHA Number101.6","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M3.5","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"DOB1.7","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":"Age101.7","page":2,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.7","page":2,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.7","page":2,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.7","page":2,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Occupation.7","page":2,"type":"text","label":"Occupation_(dd/mm"},{"name":"Relation1.7","page":2,"type":"text","label":"Relation_(dd/mm"},{"name":"Nationality101.7","page":2,"type":"text","label":"Nationality"},{"name":"ABHA Number101.7","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M3.6","page":2,"type":"text","label":"Ht. (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. 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