{"id":2464,"title":"PROPOSAL FORM HEALTH ENSURE","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/health-ensure/health_ensure-pf.pdf","sha256":"8ac796e4258ddadf53c9426d6b354e90f152af71f78d2b7e68819d53512f061d","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals proposing to purchase the Health Ensure insurance policy from Bajaj General Insurance. The proposer fills it to provide personal, health, and policy 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 cancellation.","Use original documents and attach photocopies where required.","Nominee for self must be Father, Mother, Son, Daughter, Spouse or Other with reason if 'Other'.","If proposer is disabled, authorized representative must sign to confirm understanding.","Agent must sign and declare having explained the form contents to the proposer.","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":"PROPOSAL FORM HEALTH ENSURE","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":"If existing policy, enter policy number","type":"text","label":"the Policy No.","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":["Yes"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"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":false,"pdf_field":""},{"help":"Enter last 4 digits of Aadhaar","type":"text","label":"Aadhaar No. Enter last 4 digits only","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status","options":["Married","Single","Divorced","Widowed"],"required":false,"pdf_field":""},{"help":"Enter number of sons and daughters","type":"text","label":"No. of children: _____Sons/____ Daughters","options":[],"required":false,"pdf_field":""},{"help":"If Other, specify","type":"choice","label":"Occupation","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana?","options":[],"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":""}],"filled_by":"proposer"},{"title":"Address Details","fields":[{"help":"Fill all communication address fields in block letters","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","options":["Matriculate","Undergraduate","Graduate","Post Graduate","Professionally Qualified"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Nationality","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Policy Period","options":["1 Year","2 years","3 years"],"required":true,"pdf_field":""},{"help":"Enter monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Policy Term","options":["1 Year","2 Years","3 Years"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy type","options":["Individual","Floater"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Premium Payment Zone","options":["Zone A","Zone B"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you an existing Bajaj General Customer","options":[],"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":"Details Of Persons To Be Insured","fields":[{"help":"","type":"checkbox","label":"ABHA Declaration","options":["I/We provide my/our consent to access my/our medical and personal records/details in ABHA for underwriting and claim authenticity"],"required":false,"pdf_field":""},{"help":"Nominee must be Father, Mother, Son, Daughter, Spouse or Other","type":"text","label":"Nominee Details: 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 and Sum Insured Details","fields":[{"help":"Specify sum insured for each member","type":"table","label":"Member Name, Sum Insured (Individual), Sum Insured (Floater)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Selection of Rider/Add on","fields":[{"help":"Available for sum insured 5,00,000 and above with extra premium","type":"choice","label":"Member Name, Non-Medical Expenses Cover (Rider) Yes/No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, specify Individual or Floater and plan opted","type":"choice","label":"Health Prime Rider","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"If yes, confirm co-payment 10% or 20%","type":"choice","label":"Do you want to opt for Voluntary Co-payment attached annexure","options":["No","Yes"],"required":false,"pdf_field":""},{"help":"Select Yes or No for each additional cover","type":"checkbox","label":"Additional Covers to be opted with extra premium: Room Rent Upgradation, Cumulative Bonus Enhancement, Sum Insured Reinstatement Benefit, Double Sum Insured for Cancer, Personal Accident, Respect Rider","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health Questionnaire","fields":[{"help":"Describe duration and amount","type":"text","label":"If Yes Please give duration and daily consumption","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Has any proposal for life, critical illness or health insurance ever been postponed, declined or accepted on special terms?","options":[],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, give details","options":[],"required":false,"pdf_field":""},{"help":"Provide family medical history details","type":"table","label":"Member Name, Relationship with Proposer, Disease Name, Age at illness","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Details","fields":[{"help":"","type":"choice","label":"Payment Mode","options":["Full Payment","Installment Payment"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Payment Details","options":["Cash","Cheque","DD","Credit Card","Debit Card","UPI"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Cheque Given By","options":["Spouse","Father","Mother","Son/Daughter","Financer","Employer/Employee"],"required":false,"pdf_field":""},{"help":"Provide transaction details","type":"text","label":"Amount, Transaction No., Transaction Date, Bank Name, Branch","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you want to open e-IA account","options":[],"required":false,"pdf_field":""},{"help":"Fill bank details for premium payments","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","fields":[{"help":"","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"If applicable, intermediary signs","type":"signature","label":"Signature of Intermediary","options":[],"required":false,"pdf_field":""},{"help":"If applicable, witness signs","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"If yes, provide details and attach Disability Certificate","type":"yes-no","label":"Any Physical deformity or handicap? Yes/No","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer or authorized representative"},{"title":"Portability Form","fields":[{"help":"Explain reason for portability","type":"text","label":"Reason(s) of portability","options":[],"required":true,"pdf_field":""},{"help":"Sign to confirm portability details","type":"signature","label":"Signature of Policyholder","options":[],"required":true,"pdf_field":""},{"help":"","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":"Health Ensure insurance policy proposals","attachments":["Photocopy of the existing policy documents","Disability Certificate issued by the Medical Board appointed by the Government (if applicable)","Annexure for Respect Rider details (if opted)"],"declarations":["The proposer declares that all information provided is true and complete to the best of their knowledge.","The proposer consents to the company seeking medical information from doctors, hospitals, employers, and other insurers for underwriting and claims.","The proposer authorizes sharing of proposal and medical records with reinsurers and regulatory authorities.","The proposer agrees to notify any change in occupation or health before risk acceptance.","The agent declares having explained the proposal form contents to the proposer in vernacular language if required.","The proposer agrees to observe additional waiting periods if PED exclusions are longer than previous policy.","The proposer consents to KYC verification through CERSAI or NSDL portals.","The proposer declares premiums are paid from legally acquired sources.","The proposer consents or declines sharing personal information with group companies for marketing."],"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/2464-proposal-form-health-ensure"}