{"id":2456,"title":"My Health Care Super Top-Up Plan (Plan 8) Proposal Form","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/my-health-care-plan-8-(super-top-up)-collaterals/My-Health-Care-Super-Top-Up-Plan-(Plan-8)-PF-Offline.pdf","sha256":"f811364ae245becfc94d08d7a9ebe129ba39ec81f53cb798178336e991521149","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to purchase the My Health Care Super Top-Up Plan insurance policy from Bajaj General Insurance. The proposer fills it to provide personal, health, and policy 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.","Use original and accurate information; non-disclosure may lead to policy being void.","Nominee for proposer must be a close relative as specified.","Fitness discount requires details of marathon run within 12 months.","Income commensuration is mandatory in event of claim for loss of income and hospital daily cash benefit.","Attach photocopy of existing policy documents for portability.","If the proposal form is explained in vernacular language, the content explanation must be confirmed.","Disability declaration requires authorized representative consent if proposer is disabled.","Submission of proposal or payment does not oblige the company to issue a policy.","No rebate of commission or premium is allowed as per Insurance Act 1938 Section 41."],"title":"My Health Care Super Top-Up Plan (Plan 8) Proposal Form","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":"Select Yes or No; if Yes, provide policy and PID numbers","type":"choice","label":"Are you an existing Bajaj General Customer: Yes No, if Yes please share below details a. the Policy No. b. Existing Customer (PID) No.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick 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":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender: Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter 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":null,"pdf_field":""},{"help":"Enter last 4 digits of Aadhaar","type":"text","label":"Aadhaar No. Enter last 4 digits only","options":[],"required":null,"pdf_field":""},{"help":"If applicable, enter employee code","type":"text","label":"Bajaj Employee Code, if Proposer is General/Life Employee","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status: Married Single Divorced Widowed","options":["Married","Single","Divorced","Widowed"],"required":null,"pdf_field":""},{"help":"Enter number of sons and daughters","type":"number","label":"No. of children: Sons Daughters","options":[],"required":null,"pdf_field":""},{"help":"Select 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":true,"pdf_field":""},{"help":"Select Yes or No; if Yes, provide ABHA number in persons to be insured section","type":"choice","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana? Yes No, If Yes please share your Ayushmaan Bharat Health Account Number (ABHA) in below table no 4","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Enter full 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 highest education qualification","type":"choice","label":"Educational Qualification Matriculate Under Graduate Graduate Post Graduate Professionally Qualified","options":["Matriculate","Under Graduate","Graduate","Post Graduate","Professionally Qualified"],"required":null,"pdf_field":""},{"help":"Enter monthly income in INR","type":"amount","label":"Proposer Monthly Income: INR","options":[],"required":null,"pdf_field":""},{"help":"Enter nationality","type":"text","label":"Nationality","options":[],"required":null,"pdf_field":""},{"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":"Select policy type","type":"choice","label":"Policy type Individual Floater","options":["Individual","Floater"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details Of Persons To Be Insured","fields":[{"help":"Provide details for each person to be insured including ABHA number if applicable","type":"table","label":"Name Relationship with Proposer DOB (dd/mm/yyyy) Age Gender (M/F) Ht (cms) Wt (kgs) ABHA Number","options":[],"required":true,"pdf_field":""},{"help":"Specify sum insured and deductible for each insured person","type":"table","label":"Cover offered: Super Top Up Plan In-patient Hospitalisation Sum Insured Deductible Opted","options":[],"required":true,"pdf_field":""},{"help":"Select room rent option applicable to all members","type":"choice","label":"Change in Room rent options: General Ward Twin Sharing Single Private room Actuals 1% of SI max up to 5000 1.5% of SI max 7500 2% of SI max up to 7500 Default","options":["General Ward","Twin Sharing","Single Private room","Actuals","1% of SI max up to 5000","1.5% of SI max 7500","2% of SI max up to 7500","Default"],"required":null,"pdf_field":""},{"help":"Select pre-hospitalization expense coverage days","type":"choice","label":"Pre-hospitalization Medical Expenses: 0 15 30 60 90 180 240 (Days) Default","options":["0","15","30","60","90","180","240","Default"],"required":null,"pdf_field":""},{"help":"Select post-hospitalization expense coverage days","type":"choice","label":"Post-hospitalization Medical Expenses: 0 15 30 60 90 180 240 (Days) Default","options":["0","15","30","60","90","180","240","Default"],"required":null,"pdf_field":""},{"help":"Select waiting period for pre-existing diseases","type":"choice","label":"Waiting period (pre-existing disease): 12 months 24 months Default","options":["12 months","24 months","Default"],"required":null,"pdf_field":""},{"help":"Select waiting period for specific diseases","type":"choice","label":"Waiting period (specific disease): 12 months Default 36 months","options":["12 months","Default","36 months"],"required":null,"pdf_field":""},{"help":"Select if surgery only cover required and specify sum insured","type":"choice","label":"Surgery only cover Yes No If yes specify Sum Insured amount (5,7.5,10,15,20,25 lakh)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if Health Prime Rider is opted and specify plan option","type":"choice","label":"Health Prime Rider Yes No If Yes, Individual Floater, Plan Option","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Status","fields":[{"help":"Select Yes or No; if Yes, provide details","type":"yes-no","label":"Has any proposal for life, critical illness or health insurance ever been postponed, declined or accepted on special terms? Yes No","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"Select payment mode","type":"choice","label":"Payment Mode Full Payment Installment Payment Monthly Quarterly Half Annual","options":["Full Payment","Installment Payment"],"required":true,"pdf_field":""},{"help":"Select payment mode","type":"choice","label":"Payment Details Cash Cheque DD Credit 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":"Check- Given By Spouse Father Mother Son/Daughter Employer/Employee Financier","options":["Spouse","Father","Mother","Son/Daughter","Employer/Employee","Financier"],"required":false,"pdf_field":""},{"help":"Provide transaction details for online payment","type":"text","label":"Amount Transaction No. Transaction Date Bank Name Branch","options":[],"required":false,"pdf_field":""},{"help":"Provide bank details for refund and 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 and Signature","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":""}],"filled_by":"proposer"},{"title":"Disability Declaration and Authorized Representative","fields":[{"help":"Declare any disability and provide certificate details","type":"yes-no","label":"Any Physical deformity or handicap? Yes No If Yes, provide details","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer or authorized representative"},{"title":"Agent Details and Declaration","fields":[{"help":"Agent to fill and sign","type":"text","label":"Agent/IMD Name Agent/IMD Code Agent/IMD Signature SP / BQP / DP / PoS Name SP / BQP / DP / PoS CoR No. SP / BQP / DP / PoS Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"},{"title":"Acknowledgment","fields":[{"help":"For company use to acknowledge receipt 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. Date Signature of Bajaj General Official/Intermediary","options":[],"required":false,"pdf_field":""}],"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":""},{"help":"Enter DOB 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":"Explain 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":"Provide 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 To","options":[],"required":true,"pdf_field":""},{"help":"Policyholder to sign","type":"signature","label":"Signature of Policyholder","options":[],"required":true,"pdf_field":""},{"help":"Indicate if exclusions are longer","type":"choice","label":"Whether the PED exclusions / time bound exclusion have longer exclusion period than existing policy (Yes/No)","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Proposal for My Health Care Super Top-Up Plan (Plan 8)","attachments":["Photocopy of the existing policy documents"],"declarations":["The information provided is true and complete to the best of the proposer's knowledge.","The policy will be effective only after acceptance and full premium payment.","The proposer will notify any changes 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 share proposal and medical information with reinsurers and regulatory authorities.","Agent declares having explained the form contents and consequences of untrue statements or non-disclosure.","Premiums are paid from legally acquired income.","Consent to verify identity/address proof through authorized portals.","Consent to share personal information with group companies for products and services."],"dropped_labels":36},"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/2456-my-health-care-super-top-up-plan-plan-8-proposal-form"}