{"id":2449,"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/digital-pf/Health-Infinity-pf-digital.pdf","sha256":"d6aeb0c699c22471298200523f5d4d4667aaebc64bed56f19d8ec93875f8c2bb","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for the Health Infinity insurance plan. The proposer fills it to provide personal, health, and policy details for underwriting and policy issuance.","notes":["Please answer all questions in BLOCK letters.","Liability of the company starts only after acceptance of proposal and payment of premium.","Provide all information fully and accurately.","Use original documents for attachments.","Nominee for primary insured must be one of the specified relations.","For family members, primary insured will be the nominee.","If proposal form is not filled by proposer or proposer does not know English, intermediary must explain the form in vernacular language.","Attach photocopy of existing policy documents for portability.","Use the specified format for dates (DD/MM/YYYY)."],"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":"title, First Name, Surname"},{"help":"Enter existing policy number if any","type":"text","label":"the Policy No.: OG","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":"","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"],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender: Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":"Gender MFRow1"},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":"DOB1"},{"help":"Enter your PAN number","type":"text","label":"Pan No.","options":[],"required":false,"pdf_field":"PANNO1"},{"help":"Enter last 4 digits of Aadhaar number","type":"text","label":"Aadhaar No. Enter last 4 digits only","options":[],"required":false,"pdf_field":"Adhar4"},{"help":"Select your 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":"Sons, Daughters"},{"help":"Select your occupation","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","type":"yes-no","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter ABHA number if applicable","type":"text","label":"If Yes please share your Ayushmaan Bharat Health Account Number (ABHA) in below table","options":[],"required":false,"pdf_field":"ABHA Number101.0.0"}],"filled_by":"proposer"},{"title":"Permanent / Residential Address","fields":[{"help":"Enter house number","type":"text","label":"House No.","options":[],"required":true,"pdf_field":"House No"},{"help":"Enter house name","type":"text","label":"House Name","options":[],"required":true,"pdf_field":"House Name"},{"help":"Enter landmark or locality","type":"text","label":"Landmark/Locality","options":[],"required":true,"pdf_field":"LandmarkLocality"},{"help":"Enter road or area name","type":"text","label":"Road/Area Name","options":[],"required":true,"pdf_field":"RoadArea Name"},{"help":"Enter city or district","type":"text","label":"City/District","options":[],"required":true,"pdf_field":"CityDistrict"},{"help":"Enter state","type":"text","label":"State","options":[],"required":true,"pdf_field":"State"},{"help":"Enter pin code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":"Pin Code"},{"help":"Enter telephone number","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":"Telephone"},{"help":"Enter mobile 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"}],"filled_by":"proposer"},{"title":"Communication Address","fields":[{"help":"Enter house number","type":"text","label":"House No.","options":[],"required":true,"pdf_field":"House No_2"},{"help":"Enter house name","type":"text","label":"House Name","options":[],"required":true,"pdf_field":"House Name_2"},{"help":"Enter landmark or locality","type":"text","label":"Landmark/Locality","options":[],"required":true,"pdf_field":"LandmarkLocality_2"},{"help":"Enter road or area name","type":"text","label":"Road/Area Name","options":[],"required":true,"pdf_field":"RoadArea Name_2"},{"help":"Enter city or district","type":"text","label":"City/District","options":[],"required":true,"pdf_field":"CityDistrict_2"},{"help":"Enter state","type":"text","label":"State","options":[],"required":true,"pdf_field":"State_2"},{"help":"Enter pin code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":"Pin Code2"},{"help":"Enter telephone number","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":"Telephone_2"},{"help":"Enter mobile number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":"Mobile_2"},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":"Email_2"}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"Select highest educational qualification","type":"choice","label":"Educational Qualification: Matriculate Undergraduate Graduate Post Graduate Professionally Qualified","options":["Matriculate","Undergraduate","Graduate","Post Graduate","Professionally Qualified"],"required":false,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":"ii Nationality"},{"help":"Enter monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":"Monthly Income"},{"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":"Enter start and end date of proposed insurance","type":"date","label":"Proposed period of Insurance From to","options":[],"required":true,"pdf_field":"DD2"}],"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":"NameRow1, Relationship with ProposerRow1, DOB ddmmyyRow1, AgeRow1, Gender MFRow1, Ht cmsRow1, Wt kgsRow1, Per Day Room RentRow1, Copayment Option 15  20  25Row1, ABHA Number101.0.0"}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee's full name","type":"text","label":"Name","options":[],"required":true,"pdf_field":"NameNominee"},{"help":"Enter nominee's date of birth","type":"date","label":"DOB (dd/mm/yyyy)","options":[],"required":true,"pdf_field":"DOB ddmmyyyyNominee"},{"help":"Enter nominee's age","type":"number","label":"Age","options":[],"required":true,"pdf_field":"AgeNominee"},{"help":"Enter relationship with proposer","type":"text","label":"Relation","options":[],"required":true,"pdf_field":"RelationNominee"},{"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":"Selection of Rider/Add on","fields":[{"help":"Select if you want Health Prime Rider","type":"yes-no","label":"Health Prime Rider Yes No","options":["Yes","No"],"required":false,"pdf_field":"Health Prime Rider"},{"help":"Select plan option","type":"choice","label":"Individual Floater Plan Option","options":["Individual","Floater"],"required":false,"pdf_field":"Plan Option"}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Select yes or no","type":"yes-no","label":"Do you smoke cigarettes or consume tobacco (chewing paste) / alcohol, nicotine or marijuana in any form?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if answered yes","type":"text","label":"If Yes Please give duration and daily consumption","options":[],"required":false,"pdf_field":"If Yes Please give duration and daily consumption"},{"help":"Select yes or no and provide details if yes","type":"yes-no","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":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"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 tumour 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, epilepsy, slipped disc, backache, any congenital/birth defects/urinary diseases, AIDS or positive HIV.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Have you or any of the persons proposed to be insured were/are detected as COVID positive?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"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?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details for each illness or injury","type":"table","label":"If the reply is YES to any questions from a. to f. above, please share details in below table: Name of the person, Name of the Illness /injury suffered / suffering in the past, Treatment details, Date first treated, Current Status of the Illness/ Diseases/Injury","options":[],"required":false,"pdf_field":"Name of the personRow1, Name of the Illness injury suffered  suffering in the pastRow1, Treatment detailsRow1, Date first treatedRow1.0, Current Status of the Illness DiseasesInjuryRow1"},{"help":"Select yes or no and provide age details if yes","type":"yes-no","label":"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":false,"pdf_field":""},{"help":"Provide family medical history details","type":"table","label":"Member Name, Relationship with Proposer, Disease Name, At what Age illness suffered","options":[],"required":false,"pdf_field":"Member NameRow1, Relationship with ProposerRow1_2, Disease NameRow1, At whatAge illness sufferedRow1.0"}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"Select payment mode","type":"choice","label":"Payment Mode: Full Payment Instalment Payment Monthly Quarterly Half Annual","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 cheque if applicable","type":"choice","label":"Cheque Given By: Spouse Father Mother Son/Daughter Financer Employer","options":["Spouse","Father","Mother","Son/Daughter","Financer","Employer"],"required":false,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"BIMA ASBA Declaration (Applicable only in case Premium payment through online payment mode)","options":["I agree to debit my bank account under BIMA ASBA facility"],"required":false,"pdf_field":""},{"help":"Enter amount paid","type":"amount","label":"Amount","options":[],"required":false,"pdf_field":"Amount"},{"help":"Enter transaction number","type":"text","label":"Transaction No","options":[],"required":false,"pdf_field":"Transaction No"},{"help":"Enter transaction date","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":"TR_DATE"},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":"Bank Name"},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":false,"pdf_field":"Branch"},{"help":"Enter e-IA number if available","type":"text","label":"Electronic-Insurance Account: Please provide e-IA No. to deposit your insurance policy.","options":[],"required":false,"pdf_field":"e-iA Policy"},{"help":"Select yes or no","type":"yes-no","label":"Do you want to open e-IA account Yes No","options":["Yes","No"],"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":"Name as per Bank Account, Name of the Bank, IFSC Code, Bank Account No, Account Type, Mobile No, Email Address"},{"help":"Select preferred contact mode","type":"choice","label":"In case of any Offer, you would prefer to be contacted by: Phone Email WhatsApp","options":["Phone","Email","WhatsApp"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration","fields":[{"help":"Intermediary to sign and date","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":"Signature Of Intermediary, Date 3, Place 3"},{"help":"Tick and provide details if applicable","type":"checkbox","label":"Disability Declaration: Any Physical deformity or handicap? Yes/No. If Yes, provide details and Disability Certificate","options":["Yes","No"],"required":false,"pdf_field":"Disability Certificate"}],"filled_by":"proposer"},{"title":"Agent Details and Declaration","fields":[{"help":"Enter agent or IMD name","type":"text","label":"Agent/IMD Name","options":[],"required":true,"pdf_field":"Agent Name"},{"help":"Enter agent or IMD code","type":"text","label":"Agent/IMD Code","options":[],"required":true,"pdf_field":"Agent Code"},{"help":"Agent to sign","type":"signature","label":"Agent/IMD Signature","options":[],"required":true,"pdf_field":"Signature Of Agent"},{"help":"SP/BQP/DP/PoS to sign","type":"signature","label":"SP/BQP/DP/PoS Signature","options":[],"required":false,"pdf_field":"SP/BQP/DP/PoS Sign"}],"filled_by":"agent"},{"title":"Acknowledgment","fields":[{"help":"Acknowledgment of payment receipt by company","type":"text","label":"Received from Ms. / Mrs. / Mr: sum of Rs. through Cash / Cheque / DD / Credit Card / Debit Card No. Date","options":[],"required":false,"pdf_field":"Received from Ms  Mrs  Mr, sum of Rs, through Cash  Cheque  DD  Credit Card  Debit Card No, Date"},{"help":"Company official or intermediary to sign","type":"signature","label":"Signature of Bajaj General Official/ Intermediary","options":[],"required":false,"pdf_field":"Sign Bajaj Allianz Offical, Bajaj Allianz Official  Intermediary Name, Time, Place"}],"filled_by":"company"},{"title":"Portability Form","fields":[{"help":"Enter policyholder name","type":"text","label":"Name of the Policyholder / insured(s)","options":[],"required":true,"pdf_field":"NameofthePolicyholderinsureds"},{"help":"Enter date of birth or age","type":"date","label":"Date of Birth / Age","options":[],"required":true,"pdf_field":"Dateof Birth Age"},{"help":"Enter address","type":"text","label":"Address of policyholder /insured","options":[],"required":true,"pdf_field":"Address of policyholder insured"},{"help":"Provide reason(s) for portability","type":"text","label":"Reason(s) of portability","options":[],"required":false,"pdf_field":"Reason s of portability"},{"help":"Enter number of family members to port","type":"number","label":"No of family member to be included in the policy to be ported","options":[],"required":false,"pdf_field":"Noof family member to be included in the policy tobeported"},{"help":"Attach photocopy of existing policy documents","type":"attachment","label":"Enclosure: Photocopy of the existing policy documents","options":[],"required":true,"pdf_field":""},{"help":"Policyholder to sign and date","type":"signature","label":"Signature of Policyholder","options":[],"required":true,"pdf_field":"Signature Of Policyholder"},{"help":"Select yes or no","type":"yes-no","label":"Whether the PED exclusions / time bound exclusion have longer exclusion period than existing policy (Yes/No)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Sign declaration if applicable","type":"signature","label":"If yes, please give written consent to the declaration below","options":[],"required":false,"pdf_field":"Signature Of Policyholder"}],"filled_by":"proposer"},{"title":"PEP Declaration and Consent","fields":[{"help":"Select yes or no","type":"yes-no","label":"Are you or any of the proposal applicants a PEP or a close relative of PEP? 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No555","page":5,"type":"radiobutton","options":["Choice3","Choice3"]}],"fillable_pdf":true,"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/2449-proposal-form-health-infinity"}