{"id":2446,"title":"PROPOSAL FORM HEALTH INFINITY","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/health-Infinity/Health-Infinity-proposal-form.pdf","sha256":"2698c7b2ae1bfb1d0e40acc7cbf29f527da77926278329c61f93dacfd12e384d","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for the Health Infinity insurance plan by Bajaj General Insurance. The proposer fills it to provide personal, health, and policy details for underwriting and policy issuance.","notes":["Answer all questions in BLOCK letters.","The liability of the company starts only after acceptance of proposal and premium payment.","Provide all information fully and accurately.","Use original documents where required.","Nominee for self must be Father, Mother, Son, Daughter, Spouse or Other with reason if 'Others'.","If form is filled by intermediary or proposer does not know English, declaration in vernacular language and witness signature required.","No rebate of commission or premium is allowed except as per published prospectus.","Attach photocopy of existing policy documents for portability.","Disability declaration requires government-issued certificate.","Payment details must be provided accurately.","Agent must declare having explained the form contents to proposer."],"title":"PROPOSAL FORM HEALTH INFINITY","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":"If existing policy, enter policy number","type":"text","label":"the Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Enter if you are an existing customer","type":"text","label":"Existing Customer (PID) No.","options":[],"required":false,"pdf_field":""},{"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":["I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"],"required":false,"pdf_field":""},{"help":"","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 number","type":"text","label":"Aadhaar No. Enter last 4 digits only","options":[],"required":false,"pdf_field":""},{"help":"","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":"If Other, specify","type":"choice","label":"Occupation","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":false,"pdf_field":""},{"help":"If Yes, provide ABHA number in the table below","type":"yes-no","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana?","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Enter full permanent address","type":"text","label":"Permanent /Residential Address","options":[],"required":true,"pdf_field":""},{"help":"Enter full communication address","type":"text","label":"Communication Address (all communications will be sent to below)","options":[],"required":true,"pdf_field":""},{"help":"Enter telephone number","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"","type":"choice","label":"Educational Qualification","options":["Matriculate","Undergraduate","Graduate","Post Graduate","Professionally Qualified"],"required":false,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":""},{"help":"Enter monthly income in rupees","type":"amount","label":"Proposer Monthly Income","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Policy Term","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"Enter start and end date of proposed insurance","type":"date","label":"Proposed period of Insurance From to","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details Of Persons To Be Insured","fields":[{"help":"Fill details for each person to be insured","type":"table","label":"Name, Relationship with Proposer, DOB (dd/mm/yy), Age, Gender (M/F), Ht. (cms), Wt. (kgs), Per Day Room Rent, Co-payment Option 15% / 20% / 25%, ABHA Number","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Fill nominee details; nominee for self must be Father, Mother, Son, Daughter, Spouse or Other","type":"table","label":"Name, DOB (dd/mm/yyyy), Age, Relation, Nominee*, Appointee (If nominee is minor)","options":[],"required":true,"pdf_field":""},{"help":"Explain 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":""}],"filled_by":"proposer"},{"title":"Selection of Rider/Add on","fields":[{"help":"","type":"choice","label":"Health Prime Rider","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select plan option","type":"choice","label":"Plan Option","options":["Individual","Floater"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Provide duration and daily consumption details","type":"text","label":"If Yes Please give duration and daily consumption","options":[],"required":false,"pdf_field":""},{"help":"If yes, give details","type":"yes-no","label":"Has any proposal for life, critical illness or health insurance ever been postponed, declined or accepted on special terms?","options":[],"required":true,"pdf_field":""},{"help":"Provide family medical history","type":"table","label":"Member Name, Relationship with Proposer, Disease Name, At what Age illness suffered","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"","type":"choice","label":"Payment Mode","options":["Full Payment","Instalment Payment"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Payment Details","options":["Cash","Cheque","DD","Credit Card","Debit Card","UPI"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Cheque Given By","options":["Spouse","Father","Mother","Son/Daughter","Financer","Employer"],"required":false,"pdf_field":""},{"help":"Applicable if premium paid online","type":"checkbox","label":"BIMA ASBA Declaration","options":["Consent to debit bank account upon acceptance of proposal"],"required":false,"pdf_field":""},{"help":"Enter amount paid","type":"amount","label":"Amount","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction number","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":""},{"help":"Provide e-IA number to deposit policy","type":"text","label":"Electronic-Insurance Account","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you want to open e-IA account","options":[],"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":"","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"If form filled by intermediary, signature required","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"If Yes, provide details and attach Disability Certificate","type":"yes-no","label":"Any Physical deformity or handicap? Yes/No","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer or authorized representative"},{"title":"Agent Details and Declaration","fields":[{"help":"","type":"text","label":"Agent/IMD Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Agent/IMD Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Agent/IMD Signature","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"SP / BQP / DP / PoS Signature","options":[],"required":false,"pdf_field":""}],"filled_by":"agent"},{"title":"Acknowledgment","fields":[{"help":"Acknowledgment of payment","type":"text","label":"Received from Ms. / Mrs. / Mr: sum of Rs. through Cash# / Cheque / DD / Credit Card / Debit Card No. against your proposal for Health Policy.","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Bajaj General Official/ Intermediary","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Bajaj General Official / Intermediary Name, Time, Place","options":[],"required":false,"pdf_field":""}],"filled_by":"company official or intermediary"},{"title":"Portability Form","fields":[{"help":"","type":"text","label":"Name of the Policyholder / insured(s)","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date of Birth / Age","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address of policyholder /insured","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Reason(s) of portability","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"No of family member to be included in the policy to be ported","options":[],"required":true,"pdf_field":""},{"help":"Fill details for each insured member","type":"table","label":"First Name of Insured, Details of previous health insurance policy / Policy number, Health Id card number, Sum Insured, CB, Previous Insurance First policy inception date From dd/mm/yy To dd/mm/yy","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Whether the PED exclusions / time bound exclusion have longer exclusion period than existing policy (Yes/No)","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Policyholder","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Politically Exposed Persons (PEP) Declaration","fields":[{"help":"If yes, provide details","type":"yes-no","label":"Are you or any of the proposal applicants a PEP or a close relative of PEP?","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Health Infinity Plan proposal","attachments":["Photocopy of the existing policy documents","Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability"],"declarations":["The statements and particulars given are true and complete to the best of my knowledge.","The policy will come into force only after full payment of premium.","I will notify any change in occupation or health after proposal submission but before risk acceptance.","I consent to the company seeking medical information from doctors, hospitals, employers, and insurers for underwriting and claims.","I authorize the company to collect and share my personal and medical information from ABHA for underwriting and claims.","I agree to observe additional waiting periods if PED exclusions are longer than previous policy.","Premium has been paid from legally acquired sources and future premiums will be paid similarly.","I consent to share my personal information with group companies and others as per privacy policies."],"dropped_labels":20},"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/2446-proposal-form-health-infinity"}