{"id":2463,"title":"PROPOSAL FORM GLOBAL HEALTH CARE","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/Global-Health-Care/GHC-Proposal-Form.pdf","sha256":"09b294f5ac687d4ea06fe6f50827d825fa423fe96580c92a12ae663c297ec361","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) applying for the Global Health Care insurance policy to provide personal, health, and plan details for underwriting and policy issuance.","notes":["Please answer all questions in BLOCK letters.","The liability of the company does not commence until the proposal is accepted and premium paid.","Provide all information fully and accurately; non-disclosure may lead to policy being void.","Use original documents and attach photocopies where required.","Nominee for self must be one of the specified relations.","If the proposer or insured has disability, an authorised representative may fill the form and must sign.","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 GLOBAL HEALTH 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":""},{"help":"Enter existing policy number if any","type":"text","label":"the Policy No.: OG____________________________________","options":[],"required":false,"pdf_field":""},{"help":"Enter if you are an existing customer","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":["I hereby confirm that, there is no change in my existing KYC details that are available from my previous/existing policy"],"required":false,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender: Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Enter date of birth 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":false,"pdf_field":""},{"help":"Enter last 4 digits of Aadhaar number","type":"text","label":"Aadhaar No. Enter last 4 digits only","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":false,"pdf_field":""},{"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":false,"pdf_field":""},{"help":"Select yes if registered under Ayushmaan Bharat Yojana","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":"Provide 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":""},{"help":"Select yes if you are an existing customer","type":"yes-no","label":"Are you an existing Bajaj General Customer: Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter employee code if applicable","type":"text","label":"Bajaj General Employee Code, if Proposer is Bajaj General/Bajaj Life Employee","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Enter your communication address","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 your highest educational qualification","type":"choice","label":"Educational Qualification","options":["Matriculate","Under Graduate","Graduate","Post Graduate","Professionally Qualified"],"required":false,"pdf_field":""},{"help":"Enter your monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":""},{"help":"Enter your country of residence","type":"text","label":"Country of Residence","options":[],"required":false,"pdf_field":""},{"help":"Enter your citizenship","type":"text","label":"Citizenship","options":[],"required":false,"pdf_field":""},{"help":"Enter your passport number if any","type":"text","label":"Passport Number","options":[],"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":"Member Name, Relationship with Proposer, DOB (dd/mm/yy), Age, Gender (M/F), Ht. (cms), Wt. (kgs), Residential Status (Indian residing in India/NRI/PIO or OCI residing in India/Expat residing in India), Country of Residence, ABHA Number","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Provide nominee details; nominee for self must be Father/Mother/Son/Daughter/Spouse/Other","type":"text","label":"Name, DOB (dd/mm/yyyy), Age, Relation, Nominee, Appointee (If nominee is minor), If Nominee is 'Others' please specify the relationship and reason","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Plan Details","fields":[{"help":"Select one plan","type":"choice","label":"Please select Plan: Imperial, Imperial Plus","options":["Imperial","Imperial Plus"],"required":true,"pdf_field":""},{"help":"Select area of cover","type":"choice","label":"Please select area of cover: Excluding USA, Including USA","options":["Excluding USA","Including USA"],"required":true,"pdf_field":""},{"help":"Select yes to opt for dental benefits","type":"yes-no","label":"If you want to opt for Dental Plan Benefits (Optional Cover) Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select deductible option if applicable","type":"choice","label":"Please select deductible option (deductible is applicable only for International Cover): No deductible, USD 500, USD 1000","options":["No deductible","USD 500","USD 1000"],"required":false,"pdf_field":""},{"help":"Select sum insured options for Imperial Plan","type":"table","label":"IMPERIAL PLAN SUM INSURED OPTIONS (Please tick the required Sum Insured) - Member Name, Domestic SI-INR 3,750,000, International SI- USD 100,000, Domestic SI-INR 5,600,000, International SI- USD 150,000, Domestic SI- INR 7,500,000, International SI- USD 200,000","options":[],"required":false,"pdf_field":""},{"help":"Select sum insured options for Imperial Plus Plan","type":"table","label":"IMPERIAL PLUS SUM INSURED OPTIONS (Please tick the required Sum Insured) - Member Name, Domestic SI- INR 11,200,000, International SI- USD 300,000, Domestic SI- INR 18,750,000, International SI- USD 500,000, Domestic SI- INR 37,500,000, International SI- USD 1,000,000","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Selection of Rider/Add on","fields":[{"help":"Select yes to opt for Health Prime Rider","type":"yes-no","label":"Health Prime Rider Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select plan option for rider","type":"choice","label":"Individual Floater Plan Option","options":["Individual","Floater"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Answer yes or no and provide details if yes","type":"yes-no","label":"Do you smoke cigarettes or consume tobacco (chewing paste) / alcohol, nicotine or marijuana in any form? If Yes Please give duration and daily consumption?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no and provide details if yes","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? If yes, give details","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"Have you or any of the members proposed to be insured ever had or been told to have or been treated for: a. epilepsy, fits, stroke, paralysis, weakness of limb, prolonged headache, unconsciousness, nervous breakdown, depression or any other nervous/mental (Psychiatry and psychotherapy) disorders?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"b. diabetes, thyroid disorders or any other endocrine disorders?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"c. ear discharge, nose bleeds, double vision, impaired sight, hearing, or speech or any other disorders of ear, eye, nose or throat?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"d. asthma, persistent cough, coughing with blood, pneumonia, tuberculosis, chest or breathing complaints/discomfort or any other lung disorders?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"e. raised cholesterol, high blood pressure, heart attack, heart murmur, cardiomyopathy, mitral valve prolapse or other heart valve disorders, breathlessness, irregular or fast heart rate, chest discomfort or pain, disease of or any other disorders of the heart or blood vessels?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"f. gastritis, stomach or duodenal ulcer, blood in stools, fistula, piles or any other stomach or bowel disorders?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"g. jaundice, hepatitis B carrier or any form of hepatitis, liver disorder or gall bladder disorder?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"h. blood, protein or sugar in urine, kidney stones, infection or any other disorders of the kidney, bladder or genital organs?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"i. slipped disc, gout, arthritis, pain or deformity or disorders of the muscles, spine, limbs or joints or severe injury?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"j. cancer, tumours, cysts or growths of any kind?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"k. anaemia, any other disorders of the blood, advised to abstain from donating blood or received blood transfusion or blood products on account of haemophilia or any other reason?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"l. any other illness, disorder, operation, physical disability or accident not mentioned above?","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 (self/ prescribed) or planned for any treatment / surgery / hospitalization?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of illness or injury if answered yes","type":"table","label":"If the reply is YES to any questions from 1. to 3. 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":""},{"help":"Answer yes or no and provide details if yes","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 if applicable","type":"table","label":"Member Name, Relationship with Proposer, Disease Name, At what Age illness suffered","options":[],"required":false,"pdf_field":""},{"help":"Answer yes or no and provide details if yes","type":"yes-no","label":"Have you or any of the persons proposed to be insured were/are detected as Covid positive? (If Yes, Give Date of Detection and Treatment Details)","options":["Yes","No"],"required":false,"pdf_field":""}],"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 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":"Tick if paying premium online via BIMA ASBA","type":"checkbox","label":"BIMA ASBA Declaration (Applicable only in case Premium payment through online payment mode)","options":["I agree to use BIMA ASBA facility and debit my bank account upon acceptance of this proposal"],"required":false,"pdf_field":""},{"help":"Provide transaction details for payment","type":"text","label":"Amount, Transaction No., Transaction Date, Bank Name, Branch","options":[],"required":false,"pdf_field":""},{"help":"Select yes to open e-IA account","type":"yes-no","label":"Electronic-Insurance Account: Please provide e-IA No. to deposit your insurance policy. Do you want to open e-IA account Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide bank details for 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":""},{"help":"Select preferred contact method","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":"Signature of intermediary if applicable","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"Declare if any physical disability","type":"yes-no","label":"Any Physical deformity or handicap? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details and attach Disability Certificate issued by Government Medical Board","type":"text","label":"If Yes. Please provide details","options":[],"required":false,"pdf_field":""}],"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":""},{"help":"Agent or point of sale details and signature","type":"text","label":"SP / BQP / DP / PoS Name, SP / BQP / DP / PoS CoR No., SP / BQP / DP / PoS Signature","options":[],"required":false,"pdf_field":""}],"filled_by":"agent"},{"title":"Portability Form","fields":[{"help":"Enter name of policyholder","type":"text","label":"Name of the Policyholder / insured(s)","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth 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":"State reason(s) for portability","type":"text","label":"Reason(s) of portability","options":[],"required":true,"pdf_field":""},{"help":"Enter number of family members to port","type":"number","label":"No of family member to be included in the policy to be ported","options":[],"required":true,"pdf_field":""},{"help":"Provide details of previous insurance 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":true,"pdf_field":""},{"help":"Attach photocopy of existing policy documents","type":"attachment","label":"Enclosure: Photocopy of the existing policy documents","options":[],"required":true,"pdf_field":""},{"help":"Policyholder to sign","type":"signature","label":"Signature of Policyholder","options":[],"required":true,"pdf_field":""},{"help":"Indicate if exclusions have longer period","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":""},{"help":"Sign declaration if exclusions have longer period","type":"signature","label":"If yes, please give written consent to the declaration below","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Politically Exposed Persons (PEP) Declaration and Consent","fields":[{"help":"Declare if PEP or close relative","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":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Global Health Care insurance proposals","attachments":["Photocopy of the existing policy documents","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, employers, and insurers for underwriting and claims.","The proposer consents to the company collecting and sharing personal and medical information from ABHA for underwriting and claims.","The agent declares that the proposal form contents have been explained to the proposer in their vernacular language if required.","The proposer declares that premium has been paid from legally acquired sources and future premiums will be similarly paid.","The proposer consents to share personal information with Bajaj General and group companies for insurance and related services."],"dropped_labels":11},"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/2463-proposal-form-global-health-care"}