{"id":2451,"title":"PROPOSAL FORM CRITICAL ILLNESS","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/digital-pf/Critical-Illness-digital-proposal-form.pdf","sha256":"b305548641e2b2de0c00f53d4046301acf6e3be0bf99c7578e221987d5cfbdd2","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for critical illness insurance to be filled by the proposer (person seeking insurance).","notes":["Please answer all questions in BLOCK letters.","Liability of the company starts only after acceptance of proposal and payment of premium.","Proposal form and connected papers must be understood by proposer; if not in English, explained in vernacular language.","Use original documents and provide accurate information.","No rebate of commission or premium is allowed as per Insurance Act 1938 Section 41.","Submission of proposal or payment does not oblige the company to issue policy.","Attach Disability Certificate if applicable."],"title":"PROPOSAL FORM CRITICAL ILLNESS","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, Middle 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 PID number if existing customer","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 that are available from my previous/existing policy"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender: Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":"Gender.1"},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":"DOB FROM"},{"help":"Enter PAN number","type":"text","label":"Pan No.","options":[],"required":false,"pdf_field":"Pan No"},{"help":"Enter last 4 digits of Aadhaar number","type":"text","label":"Aadhaar No. Enter last 4 digits only","options":[],"required":false,"pdf_field":"Aadhaar No"},{"help":"","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":"text","label":"No. of children: Sons Daughters","options":[],"required":false,"pdf_field":""},{"help":"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":"","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 registered","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"}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"","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":"Nationality"},{"help":"Enter monthly income in rupees","type":"amount","label":"Proposer Monthly Income Rs.","options":[],"required":false,"pdf_field":"Monthly Income"},{"help":"","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":"Details Of Persons To Be Insured","fields":[{"help":"","type":"checkbox","label":"ABHA Declaration (Applicable only if you have shared the ABHA number with Us)","options":["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 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"],"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":"If Nominee is Others please specify the relationship and reason"}],"filled_by":"proposer"},{"title":"Selection of Rider/Add on","fields":[{"help":"","type":"yes-no","label":"Health Prime Rider Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select plan option and specify if applicable","type":"choice","label":"Individual Floater Plan Option","options":["Individual","Floater"],"required":false,"pdf_field":"Plan Option"}],"filled_by":"proposer"},{"title":"Insurance Information","fields":[{"help":"Enter sum insured amount","type":"amount","label":"Critical illness benefit applied for Rs.","options":[],"required":true,"pdf_field":"Critical illness benefit applied for Rs"},{"help":"If yes, provide policy number","type":"yes-no","label":"Do you have other current or pending critical illness Insurance with Bajaj General Insurance Limited? If Yes, Policy No.","options":["Yes","No"],"required":false,"pdf_field":"Policy No"},{"help":"If yes, provide institution name, sum insured and year","type":"yes-no","label":"Do you have other current or pending critical illness Insurance with another Company? If Yes, Name of Institution Sum Insured Year","options":["Yes","No"],"required":false,"pdf_field":"Insurance Another Company Name, Sum Insured, Insurance Year"},{"help":"If yes, provide details","type":"yes-no","label":"Has any proposal for Life, Accident, Disability cover, Critical Illness or any other Health-Related Insurance on your life ever been postponed, declined or accepted on special terms? If yes, give details including amount applied for","options":["Yes","No"],"required":false,"pdf_field":"If yes give details including amount applied for"}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"","type":"yes-no","label":"Are you now in good health and entirely free from any mental or physical impairments or deformities?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter weight change and reason","type":"text","label":"How much weight have you lost or gained over the last 12 months? (Kg.) Reason for weight change","options":[],"required":false,"pdf_field":"Weight, Reason For Weight Change"},{"help":"","type":"yes-no","label":"Any other diseases or ailments not mentioned above?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you ever had or been advised to have hospital treatment or surgery?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you ever had or been advised to have a blood test for AIDS or AIDS-related condition or been refused as blood donor?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you ever received or do you now receive any personal accident, disability benefit or related payments?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide name and address","type":"text","label":"Name and address of your regular medical consultant","options":[],"required":false,"pdf_field":""},{"help":"Provide details for each illness or injury","type":"table","label":"If the reply is YES to any questions from 1 to 15 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, Current Status of the Illness DiseasesInjuryRow1"}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"","type":"choice","label":"Payment Mode Full Payment Instalment Payment Monthly Quarterly Half Annual","options":["Full Payment","Instalment Payment"],"required":true,"pdf_field":""},{"help":"","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":"","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":"Enter payment amount","type":"amount","label":"Amount","options":[],"required":true,"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":"TransationDate"},{"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":"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":"Please provide eIA No to deposit your insurance policy"},{"help":"","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 payments","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 method","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 place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":"Place 3"},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":"date"}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"","type":"yes-no","label":"Any Physical deformity or handicap? Yes No","options":["Yes","No"],"required":false,"pdf_field":"Disability Certificate"},{"help":"Attach Disability Certificate issued by Medical Board","type":"text","label":"If Yes. Please provide details","options":[],"required":false,"pdf_field":"Disability Certificate"},{"help":"If proposer is disabled, authorised representative fills and signs","type":"text","label":"Name of Authorised Representative","options":[],"required":false,"pdf_field":"Name Of Authorised Representative"},{"help":"","type":"date","label":"Date","options":[],"required":false,"pdf_field":"Date 5"},{"help":"","type":"signature","label":"Signature of Authorised Representative","options":[],"required":false,"pdf_field":"sign.4"},{"help":"","type":"text","label":"Place","options":[],"required":false,"pdf_field":"Place 5"}],"filled_by":"proposer or authorised representative"},{"title":"Agent Details and Declaration","fields":[{"help":"","type":"text","label":"Agent/IMD Name","options":[],"required":true,"pdf_field":"Agent Name"},{"help":"","type":"text","label":"Agent/IMD Code","options":[],"required":true,"pdf_field":"Agent Code"},{"help":"","type":"signature","label":"Agent/IMD Signature","options":[],"required":true,"pdf_field":"sign.5"},{"help":"","type":"text","label":"SP / BQP / DP / PoS Name","options":[],"required":false,"pdf_field":"SP / BQP / DP / PoS Name"},{"help":"","type":"text","label":"SP / BQP / DP / PoS CoR No.","options":[],"required":false,"pdf_field":"SP / BQP / DP / PoS No"},{"help":"","type":"signature","label":"SP / BQP / DP / PoS Signature","options":[],"required":false,"pdf_field":"Pos Signature"},{"help":"","type":"date","label":"Date","options":[],"required":false,"pdf_field":"Date 2"},{"help":"","type":"text","label":"Place","options":[],"required":false,"pdf_field":"Place 1"}],"filled_by":"agent"}],"deadlines":[],"applies_to":"Critical Illness insurance policies","attachments":["Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability"],"declarations":["The proposer declares that all information given is true and complete to the best of their knowledge.","The policy will come into force only after full payment of premium.","The proposer will notify any change in occupation or health after submission but before acceptance.","The proposer consents to the company seeking medical information from doctors, hospitals, employers, and insurers for underwriting and claims.","The proposer consents to the company collecting and sharing personal and medical information from Ayushman Bharat Health Account (ABHA) for underwriting and claims.","Agent declares that the proposal form contents have been explained to the proposer in vernacular language if required.","Agent declares that untrue statements or non-disclosure may lead to policy being void and premiums forfeited."],"dropped_labels":23},"pdf_fields":[{"name":"Scrutiny No","page":1,"type":"text","label":"Scrutiny No._Row_1"},{"name":"Receipt No","page":1,"type":"text","label":"Receipt No._Row_1"},{"name":"policy No","page":1,"type":"text","label":"Receipt No._Row_1"},{"name":"Loan Account No","page":1,"type":"text","label":"Loan Account Number_Row_1"},{"name":"EmpLG No","page":1,"type":"text","label":"Emp/LG Code_Row_1"},{"name":"IMD Code","page":1,"type":"text","label":"IMD Code_Row_1"},{"name":"Sub IMD Code","page":1,"type":"text","label":"Sub IMD Code_Row_1"},{"name":"IMD NameRow1","page":1,"type":"text","label":"IMD Name_Row_1"},{"name":"MobileNO","page":1,"type":"text","label":"Mobile_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. 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If Yes , Policy No"},{"name":"Group No11","page":2,"type":"radiobutton","options":["Choice6","Choice6"]},{"name":"Group No11","page":2,"type":"radiobutton","options":["Choice6","Choice6"]},{"name":"Sum Insured","page":2,"type":"text","label":"undefined"},{"name":"Insurance Year","page":2,"type":"text","label":"DOB (dd/mm/yyyy)_Nominee*"},{"name":"Group No12","page":2,"type":"radiobutton","options":["Choice2","Choice2"]},{"name":"Group No12","page":2,"type":"radiobutton","options":["Choice2","Choice2"]},{"name":"If yes give details including amount applied for","page":2,"type":"text","label":"If yes, give details including amount applied for"},{"name":"Group No13","page":2,"type":"radiobutton","options":["Choice2","Choice2"]},{"name":"Group No13","page":2,"type":"radiobutton","options":["Choice2","Choice2"]},{"name":"Reason For Weight Change","page":2,"type":"text","label":"2. 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