{"id":2445,"title":"PROPOSAL FORM HEALTH GUARD","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/health-guard/Health-Guard-Proposal-Form-print.pdf","sha256":"89c82e8797446a7cb14dd2d663b31895c244146f3068ba638f0da5157b5945e9","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to purchase the Health Guard insurance policy from Bajaj General Insurance. The proposer fills it to provide personal, health, and policy details for underwriting.","notes":["Please answer all questions in BLOCK letters.","The liability of the company starts only after acceptance of the proposal and payment of premium.","Use original and accurate information; non-disclosure may lead to policy cancellation.","Nominee for self must be a close family member: Father, Mother, Son, Daughter, Spouse, or Other.","Policyholder residing in Zone B and Zone C can choose to pay premium of Zone A to avoid co-payment.","If proposer has disability, authorized representative may fill and sign the form.","Agent must explain the form contents in vernacular language if proposer does not understand English.","Keep policy contact and bank details updated for faster service.","Submission of proposal or payment does not oblige the company to issue a policy.","No rebate of commission or premium is allowed as per Insurance Act 1938 Section 41."],"title":"PROPOSAL FORM HEALTH GUARD","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":"Select Yes or No; if Yes, provide policy number","type":"choice","label":"Are you an existing Bajaj General Customer: Yes No, if Yes please share below details a. the Policy No.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide PID if existing customer","type":"text","label":"Existing Customer (PID) No.","options":[],"required":false,"pdf_field":""},{"help":"Check 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":[],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender: Male Female Other","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":"Provide employee code if applicable","type":"text","label":"Bajaj Employee Code, if Proposer is General/Life Employee","options":[],"required":false,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status: Married Single Divorced Widowed","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; if Other, specify","type":"choice","label":"Occupation Business Salaried Professional Student House wife Retired Other","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":false,"pdf_field":""},{"help":"Select Yes or No; if Yes, provide ABHA number","type":"choice","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana? Yes No, If Yes please share your Ayushmaan Bharat Health Account Number (ABHA)","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Provide full 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: 1 Year 2 Years 3 Years","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Select policy type","type":"choice","label":"Policy type Individual Floater","options":["Individual","Floater"],"required":true,"pdf_field":""},{"help":"Select premium payment zone as per your location","type":"choice","label":"Premium Payment Zone Zone A Zone B Zone C","options":["Zone A","Zone B","Zone C"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details Of Persons To Be Insured","fields":[{"help":"Provide details for each person to be insured","type":"table","label":"Name, Relationship with Proposer, DOB (dd/mm/yyyy), Age, Gender (M/F), Height (cms), Weight (kgs), ABHA Number","options":[],"required":true,"pdf_field":""},{"help":"Provide nominee details; nominee must be close family for self","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":""}],"filled_by":"proposer"},{"title":"Plan and Sum Insured Details","fields":[{"help":"Select plan and sum insured for each member","type":"table","label":"Member Name, Plan opted (Silver/Gold/Platinum), Sum Insured (Individual), Sum Insured (Floater)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Selection of Rider/Add on","fields":[{"help":"Select Health Prime Rider and plan option","type":"choice","label":"Health Prime Rider Yes No Individual Floater Co-pay Plan Option","options":["Yes","No","Individual","Floater","Co-pay"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Answer if any genetic diseases or tests apply","type":"yes-no","label":"Have you or your spouse/partner or family member suffered from genetic disease or advised test for genetic disorders? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer about previous insurance proposals","type":"yes-no","label":"Has any proposal for life, critical illness or health insurance ever been postponed, declined or accepted on special terms? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If Yes, give details","options":[],"required":false,"pdf_field":""},{"help":"Provide family disease details if applicable","type":"table","label":"Member Name, Relationship with Proposer, Disease Name, Age at illness","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"Select payment mode and frequency","type":"choice","label":"Payment Mode Full Payment Installment Payment (Monthly, Quarterly, Half Yearly, Annual)","options":["Full Payment","Monthly","Quarterly","Half Yearly","Annual"],"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 cheque if applicable","type":"choice","label":"Cheque Given By Spouse Father Mother Son/Daughter Financer Employer/Employee","options":["Spouse","Father","Mother","Son/Daughter","Financer","Employer/Employee"],"required":false,"pdf_field":""},{"help":"Provide transaction details if applicable","type":"text","label":"Amount, Transaction No., Transaction Date, Bank Name, Branch","options":[],"required":false,"pdf_field":""},{"help":"Provide bank details for refund and 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":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration and Signature","fields":[{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Signature of agent or intermediary if applicable","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? Yes No; If Yes, provide details","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Portability Form","fields":[{"help":"Enter policyholder name","type":"text","label":"Name of the Policyholder / insured(s)","options":[],"required":true,"pdf_field":""},{"help":"Enter DOB or age","type":"date","label":"Date of Birth / Age","options":[],"required":true,"pdf_field":""},{"help":"Enter address","type":"text","label":"Address of policyholder /insured","options":[],"required":true,"pdf_field":""},{"help":"Explain reason for portability","type":"text","label":"Reason(s) of portability","options":[],"required":true,"pdf_field":""},{"help":"Attach photocopy of existing policy","type":"attachment","label":"Enclosure: Photocopy of the existing policy documents","options":[],"required":true,"pdf_field":""},{"help":"Answer about exclusion periods","type":"choice","label":"Whether the PED exclusions / time bound exclusion have longer exclusion period than existing policy (Yes/No)","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Health Guard individual and floater health insurance policies","attachments":["Photocopy of the existing policy documents"],"declarations":["The information provided is true and complete to the best of the proposer's knowledge.","The policy will be effective only after premium payment and acceptance by the company.","The proposer will notify any changes in occupation or health before acceptance.","Consent is given to the company to seek medical and insurance information for underwriting and claims.","Consent is given to share proposal and medical information with reinsurers and regulatory authorities.","The proposer authorizes refund of amounts directly to the provided bank account.","Agent declares having explained the form contents and consequences of untrue statements.","Premiums are paid from legally acquired sources.","Consent may be given to share personal data with group companies for services and products."],"dropped_labels":38},"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/2445-proposal-form-health-guard"}