{"id":2457,"title":"MY HEALTH CARE-PLAN 1 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/My-Healthcare-Plan-Final-Digital-PF.pdf","sha256":"57a6b40af9cf93c9c64a5d3230d1ab99a09ff91811495c2c6d6c308b5fd4cbfb","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to buy the My Health Care-Plan 1 health insurance policy from Bajaj General Insurance Limited. 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 commences only after acceptance of proposal and premium payment.","Use original documents for attachments where required.","If the proposal form is explained in vernacular, signatures of proposer and intermediary are required.","Keep your policy contact and bank details updated for faster service.","No person shall offer or accept rebates except as allowed by insurer's published prospectus.","Fitness discount requires details of marathon runs within last 12 months.","If opting for NRInsure, submit required NRI documents at inception and renewal.","Nominee for primary insured must be one of the specified relations.","Voluntary co-pay discount reduces premium but requires insured to bear corresponding claim percentage.","Loss of income cover is applicable only for specified members depending on policy type."],"title":"MY HEALTH CARE-PLAN 1 PROPOSAL FORM","submit":{"to":"Bajaj General Insurance Limited, as per company instructions","how":"post / in person / as per company process","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":"1 Proposer Details"},{"help":"Select Yes or No","type":"choice","label":"Are you an existing Bajaj General Customer: Yes No","options":["Yes","No"],"required":true,"pdf_field":"fill_2"},{"help":"If existing customer, provide policy number","type":"text","label":"the Policy No.","options":[],"required":false,"pdf_field":"Policy NoRow1"},{"help":"If existing customer, provide PID number","type":"text","label":"Existing Customer (PID) No.","options":[],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender: Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":"G1"},{"help":"Enter date in DDMMYYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":"D1"},{"help":"Enter your PAN number","type":"text","label":"Pan No.","options":[],"required":true,"pdf_field":"pan 10"},{"help":"Enter last 4 digits of Aadhaar","type":"text","label":"Aadhaar No. Enter last 4 digits only","options":[],"required":true,"pdf_field":"Enter last 4 digits only"},{"help":"If applicable, enter employee code","type":"text","label":"Bajaj Employee Code, if Proposer is General/Life Employee","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":true,"pdf_field":"G4"},{"help":"Enter number of sons and daughters","type":"number","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":"G5"},{"help":"Select Yes or No","type":"choice","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If registered, provide ABHA number","type":"text","label":"Ayushmaan Bharat Health Account Number (ABHA)","options":[],"required":false,"pdf_field":"ABHA NumberRow1"}],"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":true,"pdf_field":"G7"},{"help":"Enter monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":true,"pdf_field":"G8"},{"help":"Enter nationality","type":"text","label":"Nationality","options":[],"required":true,"pdf_field":"iii Nationality"},{"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":"G9"},{"help":"Select policy type","type":"choice","label":"Policy type: Individual Floater","options":["Individual","Floater"],"required":true,"pdf_field":"G10"},{"help":"Select if opting for voluntary co-pay discount","type":"choice","label":"Voluntary Co pay Discount: 5% 10% 15% 20%","options":["5%","10%","15%","20%"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Details Of Persons To Be Insured","fields":[{"help":"Provide details for each person to be insured","type":"table","label":"Name, Relationship with Proposer, DOB (dd/mm/yyyy), Age, Gender (M/F), Height (cms), Weight (kgs), ABHA Number","options":[],"required":true,"pdf_field":"NameRow1 Relationship with ProposerRow1 DOB ddmmyyyyRow1 AgeRow1 Gender MFRow1 Ht cmsRow1 Wt kgsRow1 ABHA NumberRow1"},{"help":"Fill nominee and appointee details","type":"text","label":"Nominee Details: Name, DOB (dd/mm/yyyy), Age, Relation, Nominee, Appointee (If nominee is minor), Relationship and reason if Nominee is Others","options":[],"required":true,"pdf_field":"NameNominee DOB ddmmyyyyNominee AgeNominee RelationNominee NameAppointee If nominee is minor DOB ddmmyyyyAppointee If nominee is minor AgeAppointee If nominee is minor RelationAppointee If nominee is minor"}],"filled_by":"proposer"},{"title":"Plan and Sum Insured Details","fields":[{"help":"Provide sum insured details for each member","type":"table","label":"Member Name, Sum Insured (Individual), Sum Insured (Floater)","options":[],"required":true,"pdf_field":"Member NameRow1 Sum Insured IndividualRow1.0 Sum Insured FloaterRow1"},{"help":"Select room rent option","type":"choice","label":"Change in Room rent options: General Ward, 1% of SI max up to 500, 1.5% of SI max 7500, 2% of SI max up to 7500, Default","options":["General Ward","1% of SI max up to 500","1.5% of SI max 7500","2% of SI max up to 7500","Default"],"required":false,"pdf_field":""},{"help":"Select pre-hospitalization 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opted","options":["Opted","Not opted"],"required":false,"pdf_field":""},{"help":"Select if opting for international emergency cover","type":"choice","label":"International Cover (Emergency Care only): Opted Not opted","options":["Opted","Not opted"],"required":false,"pdf_field":""},{"help":"Provide details if opting for loss of income cover","type":"table","label":"Loss of income (applicable only for Self, Spouse and dependent Parents for individual policy & Self and Spouse for floater policy): Name of Insured, Relation with proposer, Yes/No","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Fitness Discount","fields":[{"help":"Provide marathon run details for fitness discount","type":"table","label":"Name of Marathon, Date (within 12 months), No. of Kilometer run for up to 5 members","options":[],"required":false,"pdf_field":"Name of MarathonMember 1 Date within 12 monthsMember 1 No of Kilometer runMember 1"}],"filled_by":"proposer"},{"title":"Other Insurance Details","fields":[{"help":"Provide details of other insurance policies","type":"table","label":"Do you have Motor, Health, Home, Cyber and Pet Insurance with a premium more than INR 2500? If yes, provide Policy number, Policy period, LOB for up to 5 members","options":[],"required":false,"pdf_field":"Policy numberMember 1 Policy periodMember 1 LOBMember 1"}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Answer Yes or No","type":"yes-no","label":"Have you or your spouse/partner or family member suffered from or been advised tests for genetic diseases? Yes/No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer Yes or No and provide details if Yes","type":"text","label":"Has any proposal for life, critical illness or health insurance ever been postponed, declined or accepted on special terms? If yes, give details","options":["Yes","No"],"required":true,"pdf_field":"accepted on special terms If yes give details"}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"Select payment mode","type":"choice","label":"Payment Mode: Full Payment, Instalment Payment (Monthly, Quarterly, Half Yearly, Annual)","options":["Full Payment","Instalment Payment Monthly","Instalment Payment Quarterly","Instalment Payment Half Yearly","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, Financer, Employer/Employee","options":["Spouse","Father","Mother","Son/Daughter","Financer","Employer/Employee"],"required":false,"pdf_field":""},{"help":"Provide transaction details for payment","type":"text","label":"Amount, Transaction No, Transaction Date, Bank Name, Branch, Electronic-Insurance Account","options":[],"required":false,"pdf_field":""},{"help":"Select if you want to open e-IA account","type":"choice","label":"Do you want to open e-IA account? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide bank details for refund","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 Signatures","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Agent/intermediary signature","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer and agent"},{"title":"Receipt","fields":[{"help":"For office use only","type":"text","label":"Received from Ms./Mrs./Mr., sum of Rs., through Cash/Cheque/DD/Credit Card/Debit Card No., Date, Signature of Bajaj General Official/Intermediary, Name, Time, Place","options":[],"required":false,"pdf_field":"For Office Use Only"}],"filled_by":"company"},{"title":"Portability Form","fields":[{"help":"Enter 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":"Provide 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","type":"attachment","label":"Photocopy of the existing policy documents","options":[],"required":true,"pdf_field":""},{"help":"Answer Yes or No","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":"policyholder"}],"deadlines":[],"applies_to":"Individual and Floater health insurance policies under My Health Care-Plan 1","attachments":["Photocopy of the existing policy documents","Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability"],"declarations":["The information provided is true and complete to the best of my knowledge.","The policy will be issued only after premium receipt and underwriting acceptance.","I will notify any change in occupation or health before risk acceptance.","I consent to the company seeking medical and insurance information for underwriting and claims.","I authorize sharing of proposal and medical information with reinsurers and regulatory authorities.","Premiums are paid from legally acquired income.","I consent to KYC verification through authorized portals.","I understand the prohibition of rebates under Insurance Act 1938 Section 41."],"dropped_labels":35},"pdf_fields":[{"name":"d1542","page":1,"type":"text","label":"Enter last 4 digits only"},{"name":"For Office Use Only","page":1,"type":"text","label":"For Office Use Only:"},{"name":"For Agent Use Only","page":1,"type":"text","label":"For Agent Use Only:"},{"name":"Scrutiny NoRow1","page":1,"type":"text","label":"Scrutiny No._Row_1"},{"name":"Receipt NoRow1","page":1,"type":"text","label":"Receipt No._Row_1"},{"name":"Policy NoRow1","page":1,"type":"text","label":"Policy No._Row_1"},{"name":"Loan Account NumberRow1","page":1,"type":"text","label":"Loan Account Number_Row_1"},{"name":"EmpLG CodeRow1","page":1,"type":"text","label":"Emp/LG Code_Row_1"},{"name":"IMD CodeRow1","page":1,"type":"text","label":"IMD Code_Row_1"},{"name":"Sub IMD CodeRow1","page":1,"type":"text","label":"Sub IMD Code_Row_1"},{"name":"IMD NameRow1","page":1,"type":"text","label":"IMD Name_Row_1"},{"name":"Mobile NoRow1","page":1,"type":"text","label":"Mobile No_Row_1"},{"name":"1 Proposer Details","page":1,"type":"text","label":"1. 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