{"id":2459,"title":"PROPOSAL FORM EXTRA CARE PLUS","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/digital-pf/Extra-care-plus-PF-Final.pdf","sha256":"d453e5ee4348c148accd8cf6d3f013c4efb1abfa6603bba3c84ef49a7c578862","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for the Extra Care Plus health insurance policy and provide all necessary personal, health, and nominee details for underwriting and policy issuance.","notes":["Please answer all questions in BLOCK letters.","Liability of the company starts only after acceptance of proposal and payment of premium.","Provide all information fully and accurately.","Use last 4 digits only for Aadhaar number.","Nominee for self must be one of the specified relations.","Attach photocopy of existing policy documents for portability.","If proposer is disabled, authorised representative may fill and sign the form.","Agent must explain the form contents to the proposer and sign the declaration.","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 a policy."],"title":"PROPOSAL FORM EXTRA CARE PLUS","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"],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":"Group No1"},{"help":"Enter date of birth in DDMMYYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":"DOB FROM"},{"help":"Enter your 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","options":["Married","Single","Divorced","Widowed"],"required":false,"pdf_field":"Group No4"},{"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","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":false,"pdf_field":"Group No5"},{"help":"If yes, provide ABHA number in the table below","type":"yes-no","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana?","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Permanent / Residential Address","fields":[{"help":"Enter house number","type":"text","label":"House No.","options":[],"required":true,"pdf_field":"House No"},{"help":"Enter house name","type":"text","label":"House Name","options":[],"required":true,"pdf_field":"House Name"},{"help":"Enter landmark or locality","type":"text","label":"Landmark/Locality","options":[],"required":true,"pdf_field":"LandmarkLocality"},{"help":"Enter road or area name","type":"text","label":"Road/Area Name","options":[],"required":true,"pdf_field":"RoadArea Name"},{"help":"Enter city or district","type":"text","label":"City/District","options":[],"required":true,"pdf_field":"CityDistrict"},{"help":"Enter state","type":"text","label":"State","options":[],"required":true,"pdf_field":"State"},{"help":"Enter pin code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":"Pin Code"},{"help":"Enter telephone number","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":"TelephoneNo"},{"help":"Enter mobile number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":"Mobile NoRow1"},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":"Email"}],"filled_by":"proposer"},{"title":"Communication Address","fields":[{"help":"Enter house number","type":"text","label":"House No.","options":[],"required":true,"pdf_field":"House No1"},{"help":"Enter house name","type":"text","label":"House Name","options":[],"required":true,"pdf_field":"House Name_2"},{"help":"Enter landmark or locality","type":"text","label":"Landmark/Locality","options":[],"required":true,"pdf_field":"LandmarkLocality_2"},{"help":"Enter road or area name","type":"text","label":"Road/Area Name","options":[],"required":true,"pdf_field":"RoadArea Name"},{"help":"Enter city or district","type":"text","label":"City/District","options":[],"required":true,"pdf_field":"CityDistrict_2"},{"help":"Enter state","type":"text","label":"State","options":[],"required":true,"pdf_field":"State_2"},{"help":"Enter pin code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":"Pin Code1"},{"help":"Enter telephone number","type":"phone","label":"Telephone","options":[],"required":false,"pdf_field":"TelephoneNo1"},{"help":"Enter mobile number","type":"phone","label":"Mobile","options":[],"required":true,"pdf_field":"MobileNo1"},{"help":"Enter email address","type":"email","label":"Email","options":[],"required":false,"pdf_field":"Email_2"}],"filled_by":"proposer"},{"title":"Other Details","fields":[{"help":"Select your highest educational qualification","type":"choice","label":"Educational Qualification","options":["Matriculate","Under Graduate","Graduate","Post Graduate","Professionally Qualified"],"required":false,"pdf_field":"Group No7"},{"help":"Enter monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":"Monthly Income"},{"help":"Enter nationality","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":"Nationality"},{"help":"Select policy term","type":"choice","label":"Policy Term","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":"Group No9"},{"help":"Enter start date of insurance","type":"date","label":"Proposed period of Insurance From","options":[],"required":true,"pdf_field":"DOB FROM"},{"help":"Enter end date of insurance","type":"date","label":"to","options":[],"required":true,"pdf_field":"DOB TO"}],"filled_by":"proposer"},{"title":"Details Of Persons To Be Insured","fields":[{"help":"Fill details for each person to be insured","type":"table","label":"Sr No, Name, Relationship with Proposer, DOB (dd/mm/yyyy), Age, Gender (M/F), Ht. (cms), Wt. (kgs), ABHA Number","options":[],"required":true,"pdf_field":"sr. no.0, Name1, Relation1.1, DOB1.1, Age101.1, Gender.1, Ht1.0, Wt1.0, ABHA Number101.0"}],"filled_by":"proposer"},{"title":"ABHA Declaration","fields":[{"help":"Consent for accessing ABHA records for underwriting and claims","type":"checkbox","label":"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","options":["I/We provide my/ our consent"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee's full name","type":"text","label":"Name","options":[],"required":true,"pdf_field":"Nominee Name"},{"help":"Enter nominee's date of birth","type":"date","label":"DOB (dd/mm/yyyy)","options":[],"required":true,"pdf_field":"Nominee DOB"},{"help":"Enter nominee's age","type":"number","label":"Age","options":[],"required":true,"pdf_field":"Nominee Age"},{"help":"Enter nominee's relation to proposer","type":"text","label":"Relation","options":[],"required":true,"pdf_field":"Nominee Relation"},{"help":"Enter appointee details if nominee is minor","type":"text","label":"Appointee (If nominee is minor)","options":[],"required":false,"pdf_field":"Appointee Name"},{"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":"Sum Insured, Deductible & Air Ambulance Options","fields":[{"help":"Select deductible amount","type":"choice","label":"Aggregate Deductible Options","options":["200000","300000","500000","1000000"],"required":false,"pdf_field":""},{"help":"Select air ambulance cover sum insured","type":"choice","label":"Air Ambulance Cover Sum Insured (in INR)","options":["200000","300000","500000","1000000"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Selection of Rider/Add on","fields":[{"help":"Select if you want this rider (available for sum insured 5,00,000 and above)","type":"yes-no","label":"Non-Medical Expenses Cover (Rider)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if you want this rider","type":"yes-no","label":"Health Prime Rider","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if you want Respect Rider","type":"yes-no","label":"Respect Rider (If Respect Rider is opted, please furnish details in the attached annexure)","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Answer yes or no","type":"yes-no","label":"Do you smoke cigarettes or consume tobacco (chewing paste) / alcohol, nicotine or marijuana in any form?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide duration and daily consumption details","type":"text","label":"If Yes Please give duration and daily consumption","options":[],"required":false,"pdf_field":"If Yes Please give duration and daily consumption"},{"help":"Answer yes or no","type":"yes-no","label":"Has any proposal for life, critical illness or health related insurance on your life or lives ever been postponed, declined or accepted on special terms?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if answer is yes","type":"text","label":"If yes, give details","options":[],"required":false,"pdf_field":"If yes please share the details"},{"help":"Answer yes or no","type":"yes-no","label":"Has any of the persons to be insured suffer from/or investigated for any of the following? (list of diseases)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"Have you or any of the persons proposed to be insured were/are detected as COVID positive?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"Do you or any of the family members to be covered have/had any health complaints/met with any accident in the past 4 years and prior to 4 years and have been taking treatment, regular medication or planned for any treatment / surgery / hospitalization?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of illness or injury for each person","type":"table","label":"If the reply is YES to any questions from a. to f. 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":"Member NameRow1_2.0, Name of the Illnessinjury suffered suffering in the pastRow1.0.0, Treatment detailsRow1.0.0, Date first treatedRow1.0.0, Current Status of the IllnessDiseasesInjuryRow1.0.0"},{"help":"Answer yes or no and provide age details","type":"yes-no","label":"Have any of your immediate family members (father, mother, brother or sister) have/ had diabetes, hypertension, cancer, heart attack, or stroke and at What age? If yes, was it before age 60 years or after 60 years?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide family medical history details","type":"table","label":"Member Name, Relationship with Proposer, Disease Name, At what Age illness suffered","options":[],"required":false,"pdf_field":"Member Name10.0, Realtionship with Proposer.0, Disease Name10.0, Illness Suffered Age10.0"}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"Select payment mode","type":"choice","label":"Payment Mode","options":["Full Payment","Instalment Payment"],"required":true,"pdf_field":""},{"help":"Select payment method","type":"choice","label":"Payment Details","options":["Cash","Cheque","DD","Credit Card","Debit Card","UPI"],"required":true,"pdf_field":""},{"help":"Select who gave the cheque","type":"choice","label":"Cheque – Given by","options":["Spouse","Father","Mother","Son/Daughter","Employer/Employee","Financer"],"required":false,"pdf_field":""},{"help":"Consent for BIMA ASBA payment","type":"checkbox","label":"BIMA ASBA Declaration (Applicable only in case Premium payment through online payment mode)","options":["I agree to debit my bank account upon acceptance of this proposal"],"required":false,"pdf_field":""},{"help":"Enter amount paid","type":"amount","label":"Amount","options":[],"required":false,"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":"Select yes or no","type":"yes-no","label":"Do you want to open e-IA account","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter name as per bank account","type":"text","label":"Bank Details: Name as per Bank Account","options":[],"required":false,"pdf_field":"Name As Per Bank Account"},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":"Name of the Bank"},{"help":"Enter IFSC code","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":"IFSC Code"},{"help":"Enter bank account number","type":"text","label":"Bank Account No","options":[],"required":false,"pdf_field":"Bank Account No"},{"help":"Enter account type","type":"text","label":"Account Type","options":[],"required":false,"pdf_field":"Account Type"},{"help":"Enter mobile number","type":"phone","label":"Mobile No","options":[],"required":false,"pdf_field":"Mobile No"},{"help":"Enter email address","type":"email","label":"Email Address","options":[],"required":false,"pdf_field":"Email Address"},{"help":"Select preferred contact method","type":"choice","label":"In case of any Offer, you would prefer to be contacted by","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 4"},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":"date"}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"Select yes or no","type":"yes-no","label":"Any Physical deformity or handicap?","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 fills this","type":"text","label":"Name of Authorised Representative","options":[],"required":false,"pdf_field":"Name Of Authorised Representative"},{"help":"Date of authorised representative signature","type":"date","label":"Date","options":[],"required":false,"pdf_field":"Date 5"},{"help":"Signature of authorised representative","type":"signature","label":"Signature of Authorised Representative","options":[],"required":false,"pdf_field":"Sign Of Authorised Representative"},{"help":"Place of signing by authorised representative","type":"text","label":"Place","options":[],"required":false,"pdf_field":"Place 5"}],"filled_by":"proposer or authorised representative"},{"title":"Agent Details and Declaration","fields":[{"help":"Enter agent or IMD name","type":"text","label":"Agent/IMD Name","options":[],"required":true,"pdf_field":"Agent Name"},{"help":"Enter agent or IMD code","type":"text","label":"Agent/IMD Code","options":[],"required":true,"pdf_field":"Agent Code"},{"help":"Agent to sign here","type":"signature","label":"Agent/IMD Signature","options":[],"required":true,"pdf_field":"Signature Of Agent"},{"help":"Enter SP/BQP/DP/PoS name","type":"text","label":"SP / BQP / DP / PoS Name","options":[],"required":false,"pdf_field":"SP / BQP / DP / PoS Name"},{"help":"Enter SP/BQP/DP/PoS code number","type":"text","label":"SP / BQP / DP / PoS CoR No.","options":[],"required":false,"pdf_field":"SP / BQP / DP / PoS No"},{"help":"Signature of SP/BQP/DP/PoS","type":"signature","label":"SP/BQP/DP/PoS Signature","options":[],"required":false,"pdf_field":"SP/BQP/DP/PoS Sign"}],"filled_by":"agent"},{"title":"Portability Form","fields":[{"help":"Enter policyholder name","type":"text","label":"Name of the Policyholder / insured(s)","options":[],"required":true,"pdf_field":"Name of thePolicyholder  insured s"},{"help":"Enter date of birth or age","type":"date","label":"Date of Birth / Age","options":[],"required":true,"pdf_field":"Date of Birth  Age"},{"help":"Enter address","type":"text","label":"Address of policyholder /insured","options":[],"required":true,"pdf_field":"Address of policyholder insured"},{"help":"Provide reason for portability","type":"text","label":"Reason(s) of portability","options":[],"required":false,"pdf_field":"Reason s of portability"},{"help":"Enter number of family members","type":"number","label":"No of family member to be included in the policy to be ported","options":[],"required":false,"pdf_field":"No of family member to be included in the policy to be ported"},{"help":"Provide previous insurance details for each insured","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 dd/mm/yy, To dd/mm/yy","options":[],"required":false,"pdf_field":"FirstNameof InsuredRow1.0, Details of previous health insurance policy PolicynumberRow1.0, Health Id card numberRow1.0, Sum InsuredRow1.0, CBRow1.0, From ddmmyyRow1.0, To ddmmyyRow1.0, First policy inception dateRow1.0"},{"help":"Attach photocopy of existing policy documents","type":"attachment","label":"Enclosure: Photocopy of the existing policy documents","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":"Date 2"},{"help":"Policyholder to sign","type":"signature","label":"Signature of Policyholder","options":[],"required":true,"pdf_field":"Signature Of Policyholder"},{"help":"Answer yes or no","type":"yes-no","label":"Whether the PED exclusions / time bound exclusion have longer exclusion period than existing policy (Please indicate Yes /No)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Sign declaration if yes","type":"signature","label":"If yes, please give written consent to the declaration below","options":[],"required":false,"pdf_field":"Sign Of PolicyHolder"}],"filled_by":"proposer"},{"title":"Declarations – Physical Proposal Form","fields":[{"help":"Provide details if politically exposed person","type":"text","label":"Are you or any of the proposal applicants a PEP or a close relative of PEP? If yes, please share the details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Extra Care Plus health insurance proposal","attachments":["Photocopy of the existing policy documents","Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability","Details for Respect Rider in attached annexure"],"declarations":["The statements and particulars given are true and complete to the best of my knowledge.","The policy will come into force only after full payment of premium.","I will notify any change in occupation or health after submission but before acceptance.","I consent to the company seeking medical information from doctors, hospitals, employers, and insurers for underwriting and claims.","I authorize the company to collect and share my personal and medical information from ABHA for underwriting and claims.","I declare that premium has been paid from legally acquired sources.","I consent to KYC verification through CERSAI or NSDL portals.","I understand that any untrue statement or non-disclosure may lead to policy being void and forfeiture of premiums.","Agent declares that the form contents have been explained to the proposer in vernacular language if required."],"dropped_labels":11},"pdf_fields":[{"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":"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. The Policy No.: OG"},{"name":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"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"},{"name":"Group No3","page":1,"type":"radiobutton"},{"name":"Group No3","page":1,"type":"radiobutton"},{"name":"date","page":1,"type":"text","label":"Enter last 4 digits only"},{"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 No4","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1","Choice1"]},{"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":"Monthly 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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/2459-proposal-form-extra-care-plus"}