{"id":2458,"title":"MY HEALTH CARE PLAN (PLAN-6) 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-(plan-6)/MY-HEALTH-CARE-PLAN-(PLAN-6)_PF_OFFLINE.pdf","sha256":"2be0779f8c85e7394eef4c3f9147745768db9fa198a6dbc775b47379cd6d5471","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to purchase the My Health Care Plan (Plan-6) health insurance policy from Bajaj General Insurance. The proposer fills it to provide personal, health, and insurance details for underwriting.","notes":["Answer all questions in BLOCK letters.","The liability of the company starts only after acceptance and premium payment.","Use original and accurate information; non-disclosure may void the policy.","Nominee for primary insured must be a close family relation.","If proposer has disability, authorized representative may sign after explaining form.","Attach required documents for NRI status if opting for NRInsure cover.","Keep contact and bank details updated for faster service.","Submission of proposal or payment does not guarantee policy issuance.","Use the Bajaj General app or contact center to update details or for assistance."],"title":"MY HEALTH CARE PLAN (PLAN-6) 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":"","type":"choice","label":"Are you an existing Bajaj General Customer: Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If existing customer, provide policy number","type":"text","label":"the Policy No.","options":[],"required":false,"pdf_field":""},{"help":"If existing customer, provide PID number","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":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender: Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Enter your PAN number","type":"text","label":"Pan No.","options":[],"required":true,"pdf_field":""},{"help":"Enter last 4 digits of Aadhaar","type":"text","label":"Aadhaar No. Enter last 4 digits only","options":[],"required":true,"pdf_field":""},{"help":"","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":true,"pdf_field":""},{"help":"Enter number of sons and daughters","type":"number","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":true,"pdf_field":""},{"help":"","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 under Ayushmaan Bharat, provide ABHA number","type":"text","label":"Ayushmaan Bharat Health Account Number (ABHA)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Fill all communication address fields","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":"","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":""},{"help":"Enter monthly income in INR","type":"amount","label":"Proposer Monthly Income","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Nationality","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy Term 1 Year 2 Years 3 Years","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy type Individual Floater","options":["Individual","Floater"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Plan Details","fields":[{"help":"","type":"choice","label":"Sub- Plan Plan 1 Plan 2 Plan 3","options":["Plan 1","Plan 2","Plan 3"],"required":true,"pdf_field":""},{"help":"If opted, you bear corresponding % of claim","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":"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) ABHA Number","options":[],"required":true,"pdf_field":""},{"help":"Fill nominee and appointee details","type":"table","label":"Nominee Details Name DOB (dd/mm/yyyy) Age Relation Nominee Appointee (If nominee is minor)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"If Nominee is 'Others' please specify the relationship and reason","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Plan and Sum Insured Details","fields":[{"help":"Fill sum insured for each member","type":"table","label":"Member Name Sum Insured (Individual) Sum Insured (Floater)","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Sum Insured Options 3 Lacs 4 Lacs 5 Lacs 10 Lacs 20 Lacs 25 Lacs 50 Lacs 1 CR","options":["3 Lacs","4 Lacs","5 Lacs","10 Lacs","20 Lacs","25 Lacs","50 Lacs","1 CR"],"required":true,"pdf_field":""},{"help":"Default is 36 months for base plan","type":"choice","label":"Waiting period (pre-existing disease) 12 months 24 months Default","options":["12 months","24 months","Default"],"required":true,"pdf_field":""},{"help":"Default is 24 months for base plan","type":"choice","label":"Waiting period (specific disease) 12 months 36 months Default","options":["12 months","36 months","Default"],"required":true,"pdf_field":""},{"help":"Optional cover for all members","type":"choice","label":"Major Illness and Accident Multiplier Opted Not opted","options":["Opted","Not opted"],"required":false,"pdf_field":""},{"help":"Provide policy number, period, LOB for each member","type":"table","label":"Do you have Motor, Health, Home, Cyber and Pet Insurance with premium > INR 2500 with Bajaj? Provide policy details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Fill for each family member affected","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":"If installment, select frequency","type":"choice","label":"Payment Mode Full Payment Installment Payment Monthly Quarterly Half Yearly Annual","options":["Full Payment","Installment 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/Employee","options":["Spouse","Father","Mother","Son/Daughter","Financer","Employer/Employee"],"required":false,"pdf_field":""},{"help":"Fill payment transaction details","type":"text","label":"Amount Transaction No. Transaction Date Bank Name Branch","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Do you want to open e-IA account Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Fill bank details for refund and premium payment","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":true,"pdf_field":""},{"help":"Consent for refund to bank account","type":"checkbox","label":"I/We hereby authorize Bajaj General Insurance Limited to refund any amount related to my policy and/or claim directly credited to my aforesaid Bank Account","options":[],"required":true,"pdf_field":""},{"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":"","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":""},{"help":"Attach Disability Certificate if applicable","type":"text","label":"Disability Declaration Any Physical deformity or handicap? Yes No If Yes, provide details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Portability Form","fields":[{"help":"","type":"text","label":"Name of the Policyholder / insured(s)","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date of Birth / Age","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address of policyholder /insured","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Reason(s) of portability","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"No of family member to be included in the policy to be ported","options":[],"required":true,"pdf_field":""},{"help":"Fill for each family member porting","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":"","type":"yes-no","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":"My Health Care Plan (Plan-6) individual and floater health insurance policies","attachments":["Photocopy of the existing policy documents (for portability)","Disability Certificate issued by the Medical Board appointed by the Government (if applicable)","Documents for NRI verification: valid Passport with Visa, Tax Documentation, Work Visa or Employment Permit, Residential Agreement, other specified 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 premium payment.","The proposer will notify any changes in occupation or health before acceptance.","Consent to company seeking medical and insurance information for underwriting and claims.","Consent to share proposal and medical records with reinsurers and regulatory authorities.","Consent to KYC verification through CERSAI or NSDL portals.","Premiums are paid from legally acquired income sources.","Consent to block premium payment via BIMA ASBA facility if applicable.","Consent to refund amounts directly to the provided bank account.","Agreement to additional waiting periods if portability exclusions are longer.","Agent declaration confirming explanation of form contents to proposer."],"dropped_labels":29},"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/2458-my-health-care-plan-plan-6-proposal-form"}