{"id":2453,"title":"PROPOSAL FORM CRITI CARE","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/digital-pf/Criti-Care-PF-final.pdf","sha256":"385fbba58995999c95805f101b758046bf948160b1d7e8b4aa1054afc5e089f5","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a proposal form for Criti Care insurance to be filled by the proposer (policy applicant) providing personal, health, and insurance details for underwriting.","notes":["Please answer all questions in BLOCK letters.","The liability of the company does not commence until the proposal is accepted and premium paid.","This proposal is the basis of the insurance policy issued.","Use original documents and provide full and accurate information.","Nominee for self must be one of the specified relations.","For any disability, attach the government-issued Disability Certificate.","If the proposer is disabled, an authorised representative may fill and sign the form.","The form must be signed by the proposer and witnessed if filled by another person.","Agent must sign and declare having explained the form contents.","No rebate of commission or premium is allowed as per Insurance Act 1938 Section 41."],"title":"PROPOSAL FORM CRITI CARE","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":"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":["confirm"],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender: Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":"Gender.0.0"},{"help":"Enter date of birth in DDMMYYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":"DOB"},{"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":"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":"text","label":"No. of children: Sons Daughters","options":[],"required":false,"pdf_field":""},{"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":true,"pdf_field":"Occupation.0"},{"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"}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Enter full communication address 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":"House No1, House Name_2, LandmarkLocality_2, RoadArea Name, CityDistrict_2, State_2, Pin Code1, TelephoneNo1, MobileNo1, 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":true,"pdf_field":"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":""}],"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/yyyy), Age, Gender (M/F), Ht. (cms), Wt. (kgs), Occupation, Gross Monthly Income, ABHA Number","options":[],"required":true,"pdf_field":"M1.0, Relation1.0.0, DOB1.0.0, Age101.0.0, Gender.0.0, Ht.0.0, Wt.0.0, Occupation.0, Income.0, ABHA Number101.0"}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee details","type":"text","label":"Name, DOB (dd/mm/yyyy), Age, Relation, Nominee*","options":[],"required":true,"pdf_field":"NomineeName, Nominee DOB, AgeNominee, RelationNominee"},{"help":"Specify relationship and reason if nominee is other than listed","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"}],"filled_by":"proposer"},{"title":"Insurance Information","fields":[{"help":"Enter amount applied for critical illness benefit","type":"amount","label":"Critical illness benefit applied for Rs.","options":[],"required":true,"pdf_field":"Critical illness benefit applied for Rs"},{"help":"Select yes or no","type":"yes-no","label":"Do you have other current or pending critical illness Insurance with BGIL? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter policy number if yes","type":"text","label":"If Yes, Policy No.","options":[],"required":false,"pdf_field":"Policy No"},{"help":"Select yes or no","type":"yes-no","label":"Do you have other current or pending critical illness Insurance with another Company? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter details if yes","type":"text","label":"If Yes, Name of Institution, Sum Insured, Year","options":[],"required":false,"pdf_field":"Insurance Another Company Name, Sum Insured, Insurance Year"},{"help":"Select yes or no","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? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if yes","type":"text","label":"If yes, give details including amount applied for","options":[],"required":false,"pdf_field":"If yes give details including amount applied for"},{"help":"Select yes or no","type":"yes-no","label":"Have you smoked or used any substance or product containing tobacco, nicotine or marijuana? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if yes","type":"text","label":"If yes, please state duration and average daily consumption and type","options":[],"required":false,"pdf_field":"Duration And Average Daily Consumption"}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Select yes or no","type":"yes-no","label":"Are you now in good health and entirely free from any mental or physical impairments or deformities? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter height in centimeters","type":"number","label":"Height (Cm.)","options":[],"required":true,"pdf_field":"Height"},{"help":"Enter weight change in kilograms","type":"number","label":"How much weight have you lost or gained over the last 12 months? (Kg.)","options":[],"required":false,"pdf_field":"Weight"},{"help":"Explain reason for weight change","type":"text","label":"Reason for weight change","options":[],"required":false,"pdf_field":"Reason For Weight Change"},{"help":"Select yes or no","type":"yes-no","label":"Any other diseases or ailments not mentioned above? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Have you or any of your immediate family members have/had cancer, heart attack, or stroke prior to age 60? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Have you ever had or been advised to have hospital treatment or surgery? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Have you ever had or been advised to have a blood test for AIDS or an AIDS-related condition or have you ever been refused as a blood donor? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"In the past 5 years, have you consulted a physician or had any investigations other than routine employment or immigration purposes? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Have you ever received or do you now receive any personal accident, disability benefit, or disability-related payments? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Are you at present or any time in past were on any medication, special diet, or treatment? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Have you ever taken narcotics or other habit forming drugs or been treated or advised in connection with your alcohol consumption or the taking of drugs? Yes No","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":"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 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":"Check if paying via BIMA ASBA","type":"checkbox","label":"BIMA ASBA Declaration (Applicable only in case Premium payment through online payment mode)","options":["Consent to debit bank account upon acceptance"],"required":false,"pdf_field":""},{"help":"Provide transaction details","type":"text","label":"Amount, Transaction No., Transaction Date, Bank Name, Branch","options":[],"required":false,"pdf_field":"Amount, Transaction No, TransationDate, Bank Name, 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":"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 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":"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","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":"Signature Of Intermediary"}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"Select yes or no","type":"yes-no","label":"Any Physical deformity or handicap? Yes No","options":["Yes","No"],"required":false,"pdf_field":"Disability Certificate"},{"help":"Provide details and attach Disability Certificate","type":"text","label":"If Yes, please provide details","options":[],"required":false,"pdf_field":"Disability Certificate"},{"help":"If proposer is disabled, authorised representative to fill","type":"text","label":"Name of Authorised Representative","options":[],"required":false,"pdf_field":"Name Of Authorised Representative"},{"help":"Authorised representative to sign","type":"signature","label":"Signature of Authorised Representative","options":[],"required":false,"pdf_field":"Sign Of Authorised Representative"}],"filled_by":"proposer or authorised representative"},{"title":"Agent Details and Declaration","fields":[{"help":"Agent to fill name, code and sign","type":"text","label":"Agent/IMD Name, Agent/IMD Code, Agent/IMD Signature","options":[],"required":true,"pdf_field":"Agent Name, Agent Code, Signature Of Agent"}],"filled_by":"agent"},{"title":"Acknowledgment","fields":[{"help":"Company official to fill payment receipt details","type":"text","label":"Received from Ms./Mrs./Mr. sum of Rs. through Cash/Cheque/DD/Credit Card/Debit Card No.","options":[],"required":false,"pdf_field":""},{"help":"Enter date, time and place of receipt","type":"date","label":"Date, Time, Place","options":[],"required":false,"pdf_field":"Date 333, Time, Place 2"},{"help":"Company official or intermediary to sign","type":"signature","label":"Signature of Bajaj General Official/Intermediary and Name","options":[],"required":false,"pdf_field":"Sign Bajaj Allianz Offical, Bajaj Allianz Official  Intermediary Name"}],"filled_by":"company official or intermediary"},{"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? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details if yes","type":"text","label":"If yes, please share the details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Criti Care insurance proposal","attachments":["Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability"],"declarations":["The proposer declares that all information provided is true and complete to the best of their knowledge.","The policy will come into force only after full payment of the 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, past or present employers, and insurers for underwriting and claims.","The proposer consents to the company accessing and sharing ABHA data with reinsurers, service providers, and regulatory authorities for underwriting and claims.","The agent declares that the proposal form contents have been explained to the proposer in vernacular language if required.","The proposer consents to KYC verification through CERSAI or NSDL portals.","The proposer declares that premiums are paid from legally acquired sources.","The proposer consents to sharing personal information with group companies for products and services."],"dropped_labels":28},"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":"Policy 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":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Policy No OG","page":1,"type":"text","label":"a. The Policy No.: OG"},{"name":"PID NO","page":1,"type":"text","label":"b. Existing Customer (PID) No"},{"name":"Group No2","page":1,"type":"radiobutton"},{"name":"Group No3","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No3","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No3","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"DOB","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Pan No","page":1,"type":"text","label":"First Name"},{"name":"Aadhaar No","page":1,"type":"text","label":"Enter last 4 digits only"},{"name":"Employee Code","page":1,"type":"text","label":"7.Bajaj Allianz Employee Code , if Proposer is BAGIC/BALIC  Employee"},{"name":"Group No4","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1","Choice1"]},{"name":"Group 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Name"},{"name":"LandmarkLocality","page":1,"type":"text","label":"Landmark/Locality"},{"name":"LandmarkLocality_2","page":1,"type":"text","label":"Landmark/Locality"},{"name":"RoadArea Name","page":1,"type":"text","label":"Road/Area Name"},{"name":"CityDistrict_2","page":1,"type":"text","label":"City/District"},{"name":"CityDistrict","page":1,"type":"text","label":"City/District"},{"name":"CityDistrict_2","page":1,"type":"text","label":"City/District"},{"name":"State","page":1,"type":"text","label":"State"},{"name":"State_2","page":1,"type":"text","label":"State"},{"name":"Pin Code","page":1,"type":"text","label":"Pin Code:"},{"name":"Pin Code1","page":1,"type":"text","label":"Pin Code:"},{"name":"TelephoneNo","page":1,"type":"text","label":"Telephone"},{"name":"MobileNo","page":1,"type":"text","label":"Mobile"},{"name":"TelephoneNo1","page":1,"type":"text","label":"Telephone"},{"name":"MobileNo1","page":1,"type":"text","label":"Mobile"},{"name":"Email","page":1,"type":"text","label":"Email"},{"name":"Email_2","page":1,"type":"text","label":"Email"},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Group No7","page":1,"type":"radiobutton","options":["Choice6","Choice6","Choice6","Choice6","Choice6"]},{"name":"Nationality","page":1,"type":"text","label":"undefined"},{"name":"Monthly Income","page":1,"type":"text","label":"undefined"},{"name":"Group No9","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No9","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No9","page":1,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"DOB FROM","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"DOB TO","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"M1.0","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.0.0","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.0.0","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.0.0","page":1,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.0.0","page":1,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.0.0","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0.0","page":1,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Occupation.0","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"Income.0","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"ABHA Number101.0","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M1.1","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.0.1","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.0.1","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.0.1","page":1,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.0.1","page":1,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.0.1","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0.1","page":1,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Occupation.1","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"Income.1","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"ABHA Number101.2","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"M1.2","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Relation1.0.2","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"DOB1.0.2","page":1,"type":"text","label":" I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"},{"name":"Age101.0.2","page":1,"type":"text","label":"Age_(dd/mm"},{"name":"Gender.0.2","page":1,"type":"text","label":"Gende r_(dd/mm"},{"name":"Ht.0.2","page":1,"type":"text","label":"Ht. (cms)_(dd/mm"},{"name":"Wt.0.2","page":1,"type":"text","label":"Wt. (kgs)_(dd/mm"},{"name":"Occupation.2","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"Income.2","page":1,"type":"text","label":"Relation_(dd/mm"},{"name":"M1.3","page":1,"type":"text","label":"Ht. 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