{"id":2450,"title":"PROPOSAL FORM EXTRA CARE PLUS","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/extra-care-plus/Extra_care_plus_PF.pdf","sha256":"a2572bfc4df0e081ae6e267c88532f7ad69001d50ff8699fb69983886f79ca9b","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for the Extra Care Plus health insurance policy from Bajaj General Insurance. The proposer fills it to provide personal, health, and insurance details for underwriting and policy issuance.","notes":["Please answer all questions in BLOCK letters.","The liability of the company does not commence until the proposal is accepted and premium paid.","Use original documents and provide full and accurate information.","Nominee for self must be one of the specified relations.","If the proposal form is filled by an intermediary in vernacular language, signatures of proposer and intermediary are required.","Disability declaration requires a government-issued disability certificate.","Agent must sign and declare having explained the form contents.","Submission of the proposal or payment does not oblige the company to issue a policy.","Section 41 of Insurance Act 1938 prohibits rebates on commission or premium."],"title":"PROPOSAL FORM EXTRA CARE PLUS","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":"Enter existing policy number if any","type":"text","label":"the Policy No.: OG____________________________________","options":[],"required":false,"pdf_field":""},{"help":"Enter your existing customer ID if applicable","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":"Select your gender","type":"choice","label":"Gender: Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter date of birth in DDMMYYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Enter your 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":"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":""},{"help":"Select your 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","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":"Provide 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":""}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Enter your 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 your highest educational qualification","type":"choice","label":"Educational Qualification Matriculate Under Graduate Graduate Post Graduate Professionally Qualified","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: Rs.","options":[],"required":false,"pdf_field":""},{"help":"Enter your nationality","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":""},{"help":"Select the policy term","type":"choice","label":"Policy Term: 1 Year 2 Years 3 Years","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"ABHA Declaration","fields":[{"help":"Tick to give consent if ABHA number shared","type":"checkbox","label":"I/We provide my/ our consent to access my/ our (all insured) medical and personal records/ details, as are available in my/ our Ayushman Bharat Health Account (ABHA) and share the same with Third Party Administrators, Reinsurer (if applicable), Service Provider/s of Bajaj General and/or with any Governmental and/Regulatory authority for the sole purposes of underwriting my/ our proposal and/ or for checking the authenticity of claims lodged by me/ us and/ or to comply with the applicable Law/ Regulations","options":["I/We provide my/ our consent as above"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee's full name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's date of birth","type":"date","label":"DOB (dd/mm/yyyy)","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's age","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship with proposer","type":"text","label":"Relation","options":[],"required":true,"pdf_field":""},{"help":"Tick if nominee","type":"checkbox","label":"Nominee*","options":["Nominee"],"required":true,"pdf_field":""},{"help":"Enter appointee details if nominee is minor","type":"text","label":"Appointee (If nominee is minor)","options":[],"required":false,"pdf_field":""},{"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":""}],"filled_by":"proposer"},{"title":"Selection of Rider/Add on","fields":[{"help":"Select Yes to avail rider with sum insured 5,00,000 and above","type":"yes-no","label":"Non-Medical Expenses Cover (Rider) Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if opting for Respect Rider","type":"yes-no","label":"Respect Rider (If Respect Rider is opted, please furnish details in the attached annexure) Yes No","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Answer 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":""},{"help":"Answer 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":"Answer 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, ts (epilepsy) slipped disc, backache, any congenital/ birth defects/ urinary diseases, AIDS or positive HIV.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer 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":"Answer 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 if answered Yes","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":""},{"help":"Answer Yes or No and provide 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 member disease details if applicable","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":"Select payment mode","type":"choice","label":"Payment Mode Full Payment Instalment Payment Monthly Quarterly Half Annual","options":["Full Payment","Instalment Payment Monthly","Instalment Payment Quarterly","Instalment Payment Half","Instalment Payment 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 the cheque if applicable","type":"choice","label":"Cheque – Given by Spouse Father Mother Son/Daughter Employer/Employee Financer","options":["Spouse","Father","Mother","Son/Daughter","Employer/Employee","Financer"],"required":false,"pdf_field":""},{"help":"Tick if paying premium via BIMA ASBA","type":"checkbox","label":"BIMA ASBA Declaration (Applicable only in case Premium payment through online payment mode) policy under the BIMA ASBA facility and debit the same from my bank account upon acceptance of this proposal. In case the proposal is not accepted, I accord my consent to debit only the expenses incurred towards medical examination, if any, and unblock the balance amount","options":["Consent to BIMA ASBA debit"],"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 if available","type":"text","label":"Electronic-Insurance Account Please provide e-IA No. to deposit your insurance policy.","options":[],"required":false,"pdf_field":""},{"help":"Select if you want to open e-IA account","type":"yes-no","label":"Do you want to open e-IA account Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide bank account details for premium refund or 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":""},{"help":"Select preferred contact mode for offers","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":"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":"Intermediary to sign if applicable","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":""},{"help":"Enter witness name if applicable","type":"text","label":"Name of Witness","options":[],"required":false,"pdf_field":""},{"help":"Witness to sign if applicable","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"Select if you have any physical deformity or handicap","type":"yes-no","label":"Any Physical deformity or handicap? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details and attach Disability Certificate if applicable","type":"text","label":"If Yes. Please provide details","options":[],"required":false,"pdf_field":""},{"help":"If proposer is disabled, authorised representative to fill name","type":"text","label":"Name of Authorised Representative","options":[],"required":false,"pdf_field":""},{"help":"Authorised representative to sign","type":"signature","label":"Signature of Authorised Representative","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer or authorised representative"},{"title":"Agent Details and Declaration","fields":[{"help":"Agent to enter name","type":"text","label":"Agent/IMD Name","options":[],"required":true,"pdf_field":""},{"help":"Agent to enter code","type":"text","label":"Agent/IMD Code","options":[],"required":true,"pdf_field":""},{"help":"Agent to sign","type":"signature","label":"Agent/IMD Signature","options":[],"required":true,"pdf_field":""},{"help":"Agent to enter SP/BQP/DP/PoS name","type":"text","label":"SP / BQP / DP / PoS Name","options":[],"required":false,"pdf_field":""},{"help":"Agent to enter CoR number","type":"text","label":"SP / BQP / DP / PoS CoR No.","options":[],"required":false,"pdf_field":""},{"help":"Agent to sign","type":"signature","label":"SP / BQP / DP / PoS Signature","options":[],"required":false,"pdf_field":""}],"filled_by":"agent"},{"title":"Portability Form","fields":[{"help":"Enter policyholder name","type":"text","label":"Name of the Policyholder / insured(s)","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth 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":"State reason for portability","type":"text","label":"Reason(s) of portability","options":[],"required":true,"pdf_field":""},{"help":"Enter number of family members","type":"number","label":"No of family member to be included in the policy to be ported","options":[],"required":true,"pdf_field":""},{"help":"Attach photocopy of existing policy documents","type":"attachment","label":"Photocopy of the existing policy documents","options":[],"required":true,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Whether the PED exclusions / time bound exclusion have longer exclusion period than existing policy (Please indicate Yes /No)","options":["Yes","No"],"required":true,"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":""}],"filled_by":"proposer"},{"title":"Declarations – Physical Proposal Form","fields":[{"help":"Provide details if Politically Exposed Person","type":"text","label":"Are you or any of the proposal applicants a PEP* or a close relative of PEP*? If yes, please share the details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Extra Care Plus health insurance proposal","attachments":["Photocopy of the existing policy documents","Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability","Details in the attached annexure if Respect Rider is opted"],"declarations":["The information provided is true and complete to the best of the proposer's knowledge.","The policy will commence only after acceptance and full premium payment.","The proposer will notify any change in occupation or health before risk acceptance.","Consent is given to the company to seek medical and insurance information for underwriting and claims.","Consent is given to access and share ABHA data for underwriting and claims purposes.","Agent declares having explained the form contents to the proposer in vernacular language if required.","Non-disclosure or untrue statements may lead to policy cancellation and forfeiture of premiums.","Premiums are paid from legally acquired sources.","Consent is given for KYC verification through specified portals.","Consent is given for sharing personal data with Bajaj General and group companies."],"dropped_labels":16},"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/2450-proposal-form-extra-care-plus"}