{"id":2465,"title":"GLOBAL HEALTH CARE PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/digital-pf/GHC-Proposal-Form-FINAL.pdf","sha256":"5b5ee00a2cb3c712cd55053aa127186ac8c9c80905efaa0e541d4ce8527e44ea","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals (proposers) to apply for health insurance coverage under the Global Health Care plan. The proposer fills it to provide personal, health, and plan details for insurance underwriting.","notes":["Please answer all questions in BLOCK letters.","The liability of the company does not commence until the proposal is accepted and premium paid.","Use original documents and provide full and accurate information.","Nominee for self must be Father, Mother, Son, Daughter, Spouse or Other with reason if Other.","If proposer is disabled, an 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":"GLOBAL HEALTH CARE 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":"Tit, First Name, Mid 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 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","options":["Male","Female","Other"],"required":true,"pdf_field":"Gender MFRow1"},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":"DOB"},{"help":"Enter PAN number","type":"text","label":"Pan No.","options":[],"required":false,"pdf_field":"PANNO"},{"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","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 or specify if Other","type":"choice","label":"Occupation","options":["Business","Salaried","Professional","Student","House wife","Retired","Other"],"required":false,"pdf_field":""},{"help":"If Yes, provide Ayushmaan Bharat Health Account Number (ABHA) 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":"ABHA Number101.0.0.0"}],"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 monthly income in rupees","type":"amount","label":"Proposer Monthly Income: Rs.","options":[],"required":false,"pdf_field":"Proposer Monthly Income Rs"},{"help":"Enter country of residence","type":"text","label":"Country of Residence","options":[],"required":false,"pdf_field":"iii Country of Residence"},{"help":"Enter citizenship","type":"text","label":"Citizenship","options":[],"required":false,"pdf_field":"iv Citizenship"},{"help":"Enter passport number","type":"text","label":"Passport Number","options":[],"required":false,"pdf_field":"v Passport Number"}],"filled_by":"proposer"},{"title":"Details Of Persons To Be Insured","fields":[{"help":"Fill 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":"Member NameRow1, Relationship with ProposerRow1, DOB ddmmyyRow1.0, AgeRow1, Gender MFRow1, Ht cmsRow1, Wt kgsRow1, Residential Status Please mention one of the below options Indian residing in IndiaNRI PIO or OCI residing in India Expat residing in IndiaRow1, Country of ResidenceRow1, ABHA Number101.0.0.0"}],"filled_by":"proposer"},{"title":"Nominee Details","fields":[{"help":"Enter nominee details; nominee for self must be Father, Mother, Son, Daughter, Spouse or Other","type":"text","label":"Name, DOB (dd/mm/yyyy), Age, Relation, Nominee*","options":[],"required":true,"pdf_field":"Nominee Name, Nominee DOB, Nominee Age, 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, Appointee DOB, Appointee Age, Appointee Relation"},{"help":"Specify relationship and reason if nominee is Other","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":"Plan Details","fields":[{"help":"Select one plan","type":"choice","label":"Please select Plan","options":["Imperial","Imperial Plus"],"required":true,"pdf_field":"Plan Option"},{"help":"Select area of cover","type":"choice","label":"Please select area of cover","options":["Excluding USA","Including USA"],"required":true,"pdf_field":""},{"help":"Select if you want dental benefits","type":"yes-no","label":"If you want to opt for Dental Plan Benefits (Optional Cover)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select deductible option","type":"choice","label":"Please select deductible option (deductible is applicable only for International Cover)","options":["No deductible","USD 500","USD 1000"],"required":false,"pdf_field":""},{"help":"Select sum insured for Imperial Plan","type":"choice","label":"IMPERIAL PLAN SUM INSURED OPTIONS (Please tick the required Sum Insured) for Member Name","options":["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"],"required":false,"pdf_field":""},{"help":"Select sum insured for Imperial Plus Plan","type":"choice","label":"IMPERIAL PLUS SUM INSURED OPTIONS (Please tick the required Sum Insured) for Member Name","options":["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"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Selection of Rider/Add on","fields":[{"help":"Select if you want Health Prime Rider","type":"yes-no","label":"Health Prime Rider","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify plan option if applicable","type":"text","label":"Plan Option","options":[],"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":"Group Noo11111111"},{"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 for each illness listed","type":"table","label":"Have you or any of the members proposed to be insured ever had or been told to have or been treated for various listed illnesses (epilepsy, diabetes, asthma, heart disorders, cancer, etc.)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details for any positive health history","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":"Name of the personRow1, Name of the Illness injury suffered  suffering in the pastRow1, Treatment detailsRow1, Date first treatedRow1.0, Current Status of the Illness DiseasesInjuryRow1"},{"help":"Answer yes or no and provide age 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?","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 NameRow1_4, Relationship with ProposerRow1_2, Disease NameRow1, At whatAge illness sufferedRow1.0"},{"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","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 if applicable","type":"choice","label":"Cheque Given By","options":["Spouse","Father","Mother","Son/Daughter","Financer","Employer/Employee"],"required":false,"pdf_field":""},{"help":"Tick to give consent for BIMA ASBA payment","type":"checkbox","label":"BIMA ASBA Declaration (Applicable only in case Premium payment through online payment mode)","options":["I authorize BIMA ASBA facility 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 if you want to open e-IA account","type":"yes-no","label":"Do you want to open e-IA account","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter bank account details","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":"Name as per Bank Account, Name of the Bank, IFSC Code, Bank Account No, Account Type, Mobile No, Email Address"}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"Tick yes or no","type":"yes-no","label":"Any Physical deformity or handicap? Yes/No","options":["Yes","No"],"required":false,"pdf_field":"Disability Certificate"},{"help":"Provide details and attach Disability Certificate issued by Medical Board","type":"text","label":"If Yes, please provide details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer or authorised representative"},{"title":"Acknowledgment","fields":[{"help":"Company official/intermediary fills payment receipt details","type":"text","label":"Received from Ms. / Mrs. / Mr, sum of Rs, through Cash / Cheque / DD / Credit Card / Debit Card No","options":[],"required":true,"pdf_field":"Received from Ms  Mrs  Mr, sum of Rs, through Cash  Cheque  DD  Credit Card  Debit Card No"},{"help":"Company official/intermediary signs acknowledgment","type":"signature","label":"Signature of Bajaj General Official/Intermediary, Date, Time, Place","options":[],"required":true,"pdf_field":"Sign Bajaj Allianz Offical, Date, Time, Place"},{"help":"Print name of official/intermediary","type":"text","label":"Bajaj General Official / Intermediary Name","options":[],"required":true,"pdf_field":"Bajaj General Official  Intermediary Name"}],"filled_by":"company official or intermediary"},{"title":"Portability Form","fields":[{"help":"Enter policyholder name","type":"text","label":"Name of the Policyholder / insured(s)","options":[],"required":true,"pdf_field":"NameofthePolicyholderinsureds"},{"help":"Enter DOB or age","type":"date","label":"Date of Birth / Age","options":[],"required":true,"pdf_field":"Dateof Birth Age"},{"help":"Enter address","type":"text","label":"Address of policyholder / insured","options":[],"required":true,"pdf_field":"Address of policyholder insured"},{"help":"Explain 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 to port","type":"number","label":"No of family member to be included in the policy to be ported","options":[],"required":false,"pdf_field":"Noof family member to be included in the policy tobeported"},{"help":"Provide details for each insured member","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"},{"help":"Attach photocopy of existing policy documents","type":"attachment","label":"Enclosure: Photocopy of the existing policy documents","options":[],"required":true,"pdf_field":""},{"help":"Answer yes or no","type":"yes-no","label":"Whether the PED exclusions / time bound exclusion have longer exclusion period than existing policy (Yes/No)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Sign declaration agreeing to additional waiting 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","fields":[{"help":"Answer yes or no","type":"yes-no","label":"Are you or any of the proposal applicants a PEP or a close relative of PEP?","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 insurer seeking medical and insurance information from doctors, hospitals, and other insurers.","The proposer consents to the insurer accessing and sharing ABHA data for underwriting and claims settlement.","The agent declares that the proposal form contents have been explained to the proposer in vernacular language if required.","The proposer declares that premium has been paid from legally acquired sources.","The proposer consents to identity/address verification through CERSAI or NSDL portals."],"dropped_labels":18},"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":"Tit","page":1,"type":"text","label":"3) Gender:  Male  Female  Other"},{"name":"First Name","page":1,"type":"text","label":"3) Gender:  Male  Female  Other"},{"name":"Mid Name","page":1,"type":"text","label":"3) Gender:  Male  Female  Other"},{"name":"Surname","page":1,"type":"text","label":"3) Gender:  Male  Female  Other"},{"name":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Group No1","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Policy No OG","page":1,"type":"text","label":"a. The Policy No.: OG"},{"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":"DOB","page":1,"type":"text","label":"undefined"},{"name":"PANNO","page":1,"type":"text","label":"3) Gender:  Male  Female  Other"},{"name":"undefined","page":1,"type":"text","label":"undefined"},{"name":"undefined_2","page":1,"type":"text","label":"undefined"},{"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 No4","page":1,"type":"radiobutton","options":["Choice1","Choice1","Choice1","Choice1"]},{"name":"C.No","page":1,"type":"text","label":"House Name"},{"name":"D.No","page":1,"type":"text","label":"House Name"},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Group No5","page":1,"type":"radiobutton","options":["Choice2","Choice2","Choice2","Choice2","Choice2","Choice2","Choice2"]},{"name":"Other","page":1,"type":"text","label":"Occupation  Business  Salaried  Professional  Student  House wife  Retired  Other"},{"name":"Group No66666","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"Group No66666","page":1,"type":"radiobutton","options":["Choice1","Choice1"]},{"name":"House No","page":1,"type":"text","label":"House No"},{"name":"House Name","page":1,"type":"text","label":"House Name"},{"name":"House No2","page":1,"type":"text","label":"House No"},{"name":"House Name_2","page":1,"type":"text","label":"House 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":"RoadArea Name_2","page":1,"type":"text","label":"Road/Area Name"},{"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 Code2","page":1,"type":"text","label":"Pin Code:"},{"name":"Telephone_1","page":1,"type":"text","label":"Telephone"},{"name":"Mobile_1","page":1,"type":"text","label":"Mobile"},{"name":"Telephone_2","page":1,"type":"text","label":"Telephone"},{"name":"Mobile_2","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":"Proposer Monthly Income Rs","page":1,"type":"text","label":"Proposer Monthly Income: Rs"},{"name":"iii Country of Residence","page":1,"type":"text","label":"iii. Country of Residence:"},{"name":"iv Citizenship","page":1,"type":"text","label":"iv. Citizenship:"},{"name":"v Passport Number","page":1,"type":"text","label":"v. Passport Number:"},{"name":"Member NameRow1","page":1,"type":"text","label":"Member Name_Row_1"},{"name":"Relationship with ProposerRow1","page":1,"type":"text","label":"Relationship with Proposer_Row_1"},{"name":"DOB ddmmyyRow1.0","page":1,"type":"text","label":"DOB (dd/mm/yy)_Row_1"},{"name":"AgeRow1","page":1,"type":"text","label":"Age_Row_1"},{"name":"Gender MFRow1","page":1,"type":"text","label":"Gender (M/F)_Row_1"},{"name":"Ht cmsRow1","page":1,"type":"text","label":"Ht. (cms)_Row_1"},{"name":"Wt kgsRow1","page":1,"type":"text","label":"Wt. (kgs)_Row_1"},{"name":"Residential Status Please mention one of the below options Indian residing in IndiaNRI PIO or OCI residing in India Expat residing in IndiaRow1","page":1,"type":"text","label":"Residential Status (Please mention one of the below options) (Indian residing in India/NRI/ PIO or OCI residing in India/ Expat residing in India)_Row_1"},{"name":"Country of ResidenceRow1","page":1,"type":"text","label":"Country of Residence_Row_1"},{"name":"ABHA Number101.0.0.0","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Member NameRow2","page":1,"type":"text","label":"Member Name_Row_2"},{"name":"Relationship with ProposerRow2","page":1,"type":"text","label":"Relationship with Proposer_Row_2"},{"name":"DOB ddmmyyRow1.1","page":1,"type":"text","label":"DOB (dd/mm/yy)_Row_1"},{"name":"AgeRow2","page":1,"type":"text","label":"Age_Row_2"},{"name":"Gender MFRow2","page":1,"type":"text","label":"Gender (M/F)_Row_2"},{"name":"Ht cmsRow2","page":1,"type":"text","label":"Ht. (cms)_Row_2"},{"name":"Wt kgsRow2","page":1,"type":"text","label":"Wt. (kgs)_Row_2"},{"name":"Residential Status Please mention one of the below options Indian residing in IndiaNRI PIO or OCI residing in India Expat residing in IndiaRow2","page":1,"type":"text","label":"Residential Status (Please mention one of the below options) (Indian residing in India/NRI/ PIO or OCI residing in India/ Expat residing in India)_Row_2"},{"name":"Country of ResidenceRow2","page":1,"type":"text","label":"Country of Residence_Row_2"},{"name":"ABHA Number101.0.0.1","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Member NameRow3","page":1,"type":"text","label":"Member Name_Row_3"},{"name":"Relationship with ProposerRow3","page":1,"type":"text","label":"Relationship with Proposer_Row_3"},{"name":"DOB ddmmyyRow1.2","page":1,"type":"text","label":"DOB (dd/mm/yy)_Row_1"},{"name":"AgeRow3","page":1,"type":"text","label":"Age_Row_3"},{"name":"Gender MFRow3","page":1,"type":"text","label":"Gender (M/F)_Row_3"},{"name":"Ht cmsRow3","page":1,"type":"text","label":"Ht. (cms)_Row_3"},{"name":"Wt kgsRow3","page":1,"type":"text","label":"Wt. (kgs)_Row_3"},{"name":"Residential Status Please mention one of the below options Indian residing in IndiaNRI PIO or OCI residing in India Expat residing in IndiaRow3","page":1,"type":"text","label":"Residential Status (Please mention one of the below options) (Indian residing in India/NRI/ PIO or OCI residing in India/ Expat residing in India)_Row_3"},{"name":"Country of ResidenceRow3","page":1,"type":"text","label":"Country of Residence_Row_3"},{"name":"ABHA Number101.0.0.2","page":1,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Member NameRow4","page":2,"type":"text","label":"Member Name_Row_4"},{"name":"Relationship with ProposerRow5","page":2,"type":"text","label":"Relationship with Proposer_Row_3"},{"name":"DOB ddmmyy4.0","page":2,"type":"text","label":"DOB (dd/mm/yy)_Row_1"},{"name":"Age4.0","page":2,"type":"text","label":"Age_Row_3"},{"name":"Gender 4.0","page":2,"type":"text","label":"Gender (M/F)_Row_3"},{"name":"Ht 4.0","page":2,"type":"text","label":"Ht. (cms)_Row_3"},{"name":"Wt 4.0","page":2,"type":"text","label":"Wt. (kgs)_Row_3"},{"name":"Residential Status 4.0","page":2,"type":"text","label":"Residential Status (Please mention one of the below options) (Indian residing in India/NRI/ PIO or OCI residing in India/ Expat residing in India)_Row_3"},{"name":"Country of 4.0","page":2,"type":"text","label":"Country of Residence_Row_3"},{"name":"ABHA Number101.0.0.3","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Member NameRow5","page":2,"type":"text","label":"Member Name_Row_5"},{"name":"Relationship with ProposerRow4","page":2,"type":"text","label":"Relationship with Proposer_Row_4"},{"name":"DOB ddmmyy4.1","page":2,"type":"text","label":"DOB (dd/mm/yy)_Row_1"},{"name":"Age4.1","page":2,"type":"text","label":"Age_Row_3"},{"name":"Gender 4.1","page":2,"type":"text","label":"Gender (M/F)_Row_3"},{"name":"Ht 4.1","page":2,"type":"text","label":"Ht. (cms)_Row_3"},{"name":"Wt 4.1","page":2,"type":"text","label":"Wt. (kgs)_Row_3"},{"name":"Residential Status 4.1","page":2,"type":"text","label":"Residential Status (Please mention one of the below options) (Indian residing in India/NRI/ PIO or OCI residing in India/ Expat residing in India)_Row_3"},{"name":"Country of 4.1","page":2,"type":"text","label":"Country of Residence_Row_3"},{"name":"ABHA Number101.0.0.4","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Member NameRow6","page":2,"type":"text","label":"Member Name_Row_6"},{"name":"Relationship with ProposerRow6","page":2,"type":"text","label":"Relationship with Proposer_Row_4"},{"name":"DOB ddmmyy4.2","page":2,"type":"text","label":"DOB (dd/mm/yy)_Row_1"},{"name":"Age4.2","page":2,"type":"text","label":"Age_Row_3"},{"name":"Gender 4.2","page":2,"type":"text","label":"Gender (M/F)_Row_3"},{"name":"Ht 4.2","page":2,"type":"text","label":"Ht. (cms)_Row_3"},{"name":"Wt 4.2","page":2,"type":"text","label":"Wt. (kgs)_Row_3"},{"name":"Residential Status 4.2","page":2,"type":"text","label":"Residential Status (Please mention one of the below options) (Indian residing in India/NRI/ PIO or OCI residing in India/ Expat residing in India)_Row_3"},{"name":"Country of 4.2","page":2,"type":"text","label":"Country of Residence_Row_3"},{"name":"ABHA Number101.0.0.5","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Member NameRow7","page":2,"type":"text","label":"Member Name_Row_7"},{"name":"Relationship with ProposerRow7","page":2,"type":"text","label":"Relationship with Proposer_Row_4"},{"name":"DOB ddmmyy4.3","page":2,"type":"text","label":"DOB (dd/mm/yy)_Row_1"},{"name":"Age4.3","page":2,"type":"text","label":"Age_Row_3"},{"name":"Gender 4.3","page":2,"type":"text","label":"Gender (M/F)_Row_3"},{"name":"Ht 4.3","page":2,"type":"text","label":"Ht. (cms)_Row_3"},{"name":"Wt 4.3","page":2,"type":"text","label":"Wt. (kgs)_Row_3"},{"name":"Residential Status 4.3","page":2,"type":"text","label":"Residential Status (Please mention one of the below options) (Indian residing in India/NRI/ PIO or OCI residing in India/ Expat residing in India)_Row_3"},{"name":"Country of 4.3","page":2,"type":"text","label":"Country of Residence_Row_3"},{"name":"ABHA Number101.0.0.6","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Member NameRow8","page":2,"type":"text","label":"Member Name_Row_8"},{"name":"Relationship with ProposerRow8","page":2,"type":"text","label":"Relationship with Proposer_Row_4"},{"name":"DOB ddmmyy4.4","page":2,"type":"text","label":"DOB (dd/mm/yy)_Row_1"},{"name":"Age4.4","page":2,"type":"text","label":"Age_Row_3"},{"name":"Gender 4.4","page":2,"type":"text","label":"Gender (M/F)_Row_3"},{"name":"Ht 4.4","page":2,"type":"text","label":"Ht. (cms)_Row_3"},{"name":"Wt 4.4","page":2,"type":"text","label":"Wt. (kgs)_Row_3"},{"name":"Residential Status 4.4","page":2,"type":"text","label":"Residential Status (Please mention one of the below options) (Indian residing in India/NRI/ PIO or OCI residing in India/ Expat residing in India)_Row_3"},{"name":"Country of 4.4","page":2,"type":"text","label":"Country of Residence_Row_3"},{"name":"ABHA Number101.0.0.7","page":2,"type":"text","label":"ABHA Number_(dd/mm"},{"name":"Group No909011235","page":2,"type":"radiobutton"},{"name":"Appointee Name","page":2,"type":"text","label":"Appointee (If nominee is minor)"},{"name":"Appointee DOB","page":2,"type":"text","label":"DOB (dd/mm/yyyy)_Nominee*"},{"name":"Appointee Age","page":2,"type":"text","label":"Age_Nominee*"},{"name":"Appointee Relation","page":2,"type":"text","label":"Relation_Nominee*"},{"name":"Nominee Name","page":2,"type":"text","label":"Name_Nominee*"},{"name":"Nominee DOB","page":2,"type":"text","label":"DOB (dd/mm/yyyy)_Nominee*"},{"name":"Nominee Age","page":2,"type":"text","label":"Age_Nominee*"},{"name":"Nominee Relation","page":2,"type":"text","label":"Relation_Nominee*"},{"name":"If Nominee is Others please specify the relationship and reason","page":2,"type":"text","label":"If Nominee is \"Others\" please specify the relationship and reason"},{"name":"Group No1066543","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1066543","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No10665432","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No10665432","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1066543123","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1066543123","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1066543210","page":2,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No1066543210","page":2,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No1066543210","page":2,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Member NameRow1_2","page":2,"type":"text","label":"Member Name_Row_1"},{"name":"Group No50011","page":2,"type":"radiobutton"},{"name":"Group No50011","page":2,"type":"radiobutton"},{"name":"Group No50011","page":2,"type":"radiobutton"},{"name":"Member NameRow2_2","page":2,"type":"text","label":"Member Name_Row_2"},{"name":"Group No50012","page":2,"type":"radiobutton"},{"name":"Group No50012","page":2,"type":"radiobutton"},{"name":"Group No50012","page":2,"type":"radiobutton"},{"name":"Member NameRow3_2","page":2,"type":"text","label":"Member Name_Row_3"},{"name":"Group No50013","page":2,"type":"radiobutton"},{"name":"Group No50013","page":2,"type":"radiobutton"},{"name":"Group No50013","page":2,"type":"radiobutton"},{"name":"Member NameRow4","page":2,"type":"text","label":"Member Name_Row_4"},{"name":"Group No50014","page":2,"type":"radiobutton"},{"name":"Group No50014","page":2,"type":"radiobutton"},{"name":"Group No50014","page":2,"type":"radiobutton"},{"name":"Member NameRow5","page":2,"type":"text","label":"Member Name_Row_5"},{"name":"Group No50015","page":2,"type":"radiobutton"},{"name":"Group No50015","page":2,"type":"radiobutton"},{"name":"Group No50015","page":2,"type":"radiobutton"},{"name":"Member NameRow6","page":2,"type":"text","label":"Member Name_Row_6"},{"name":"Group No50016","page":2,"type":"radiobutton"},{"name":"Group No50016","page":2,"type":"radiobutton"},{"name":"Group No50016","page":2,"type":"radiobutton"},{"name":"Member NameRow7","page":2,"type":"text","label":"Member Name_Row_7"},{"name":"Group No50017","page":2,"type":"radiobutton"},{"name":"Group No50017","page":2,"type":"radiobutton"},{"name":"Group No50017","page":2,"type":"radiobutton"},{"name":"Member NameRow8","page":2,"type":"text","label":"Member Name_Row_8"},{"name":"Group No50018","page":2,"type":"radiobutton"},{"name":"Group No50018","page":2,"type":"radiobutton"},{"name":"Group No50018","page":2,"type":"radiobutton"},{"name":"Member NameRow1_3","page":2,"type":"text","label":"Member Name_Row_1"},{"name":"Group No500111","page":2,"type":"radiobutton"},{"name":"Group No500111","page":2,"type":"radiobutton"},{"name":"Group No500111","page":2,"type":"radiobutton"},{"name":"Member NameRow2_3","page":2,"type":"text","label":"Member Name_Row_2"},{"name":"Group No500122","page":2,"type":"radiobutton"},{"name":"Group No500122","page":2,"type":"radiobutton"},{"name":"Group No500122","page":2,"type":"radiobutton"},{"name":"Member NameRow3_3","page":2,"type":"text","label":"Member Name_Row_3"},{"name":"Group No500133","page":2,"type":"radiobutton"},{"name":"Group No500133","page":2,"type":"radiobutton"},{"name":"Group No500133","page":2,"type":"radiobutton"},{"name":"Member NameRow4_2","page":2,"type":"text","label":"Member Name_Row_4"},{"name":"Group No500144","page":2,"type":"radiobutton"},{"name":"Group No500144","page":2,"type":"radiobutton"},{"name":"Group No500144","page":2,"type":"radiobutton"},{"name":"Member NameRow5_2","page":2,"type":"text","label":"Member Name_Row_5"},{"name":"Group No500155","page":2,"type":"radiobutton"},{"name":"Group No500155","page":2,"type":"radiobutton"},{"name":"Group No500155","page":2,"type":"radiobutton"},{"name":"Member NameRow6_2","page":2,"type":"text","label":"Member Name_Row_6"},{"name":"Group No500166","page":2,"type":"radiobutton"},{"name":"Group No500166","page":2,"type":"radiobutton"},{"name":"Group No500166","page":2,"type":"radiobutton"},{"name":"Member NameRow7_2","page":2,"type":"text","label":"Member Name_Row_7"},{"name":"Group No500177","page":2,"type":"radiobutton"},{"name":"Group No500177","page":2,"type":"radiobutton"},{"name":"Group No500177","page":2,"type":"radiobutton"},{"name":"Member NameRow8_2","page":2,"type":"text","label":"Member Name_Row_8"},{"name":"Group No500188","page":2,"type":"radiobutton"},{"name":"Group No500188","page":2,"type":"radiobutton"},{"name":"Group No500188","page":2,"type":"radiobutton"},{"name":"Group No10665431231256","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No10665431231256","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No10664321","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No10664321","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Plan Option","page":2,"type":"text","label":"Plan Option"},{"name":"If Yes Please give duration and daily consumption","page":2,"type":"text","label":"If Yes Please give duration and daily consumption"},{"name":"Group Noo11111111","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group Noo11111111","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"terms If yes give details","page":2,"type":"text","label":"terms? If yes, give details"},{"name":"Group Noo1","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group Noo1","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1066","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1066","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1067","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1067","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122331","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122331","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122332","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122332","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122333","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122333","page":2,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122334","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122334","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122335","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122335","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122336","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122336","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122337","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122337","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122338","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122338","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122339","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1122339","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No11223310","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No11223310","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No11223311","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No11223311","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Name of the personRow1","page":3,"type":"text","label":"Name of the person_Row_1"},{"name":"Name of the Illness injury suffered  suffering in the pastRow1","page":3,"type":"text","label":"Name of the Illness /injury suffered / suffering in the past_Row_1"},{"name":"Treatment detailsRow1","page":3,"type":"text","label":"Treatment details_Row_1"},{"name":"Date first treatedRow1.0","page":3,"type":"text","label":"Date first treated_Row_1"},{"name":"Current Status of the Illness DiseasesInjuryRow1","page":3,"type":"text","label":"Current Status of the Illness/ Diseases/Injury_Row_1"},{"name":"Name of the personRow2","page":3,"type":"text","label":"Name of the person_Row_2"},{"name":"Name of the Illness injury suffered  suffering in the pastRow2","page":3,"type":"text","label":"Name of the Illness /injury suffered / suffering in the past_Row_2"},{"name":"Treatment detailsRow2","page":3,"type":"text","label":"Treatment details_Row_2"},{"name":"Date first treatedRow1.1","page":3,"type":"text","label":"Date first treated_Row_1"},{"name":"Current Status of the Illness DiseasesInjuryRow2","page":3,"type":"text","label":"Current Status of the Illness/ Diseases/Injury_Row_2"},{"name":"Name of the personRow3","page":3,"type":"text","label":"Name of the person_Row_3"},{"name":"Name of the Illness injury suffered  suffering in the pastRow3","page":3,"type":"text","label":"Name of the Illness /injury suffered / suffering in the past_Row_3"},{"name":"Treatment detailsRow3","page":3,"type":"text","label":"Treatment details_Row_3"},{"name":"Date first treatedRow1.2","page":3,"type":"text","label":"Date first treated_Row_1"},{"name":"Current Status of the Illness DiseasesInjuryRow3","page":3,"type":"text","label":"Current Status of the Illness/ Diseases/Injury_Row_3"},{"name":"Name of the personRow4","page":3,"type":"text","label":"Name of the person_Row_4"},{"name":"Name of the Illness injury suffered  suffering in the pastRow4","page":3,"type":"text","label":"Name of the Illness /injury suffered / suffering in the past_Row_4"},{"name":"Treatment detailsRow4","page":3,"type":"text","label":"Treatment details_Row_4"},{"name":"Date first treatedRow1.3","page":3,"type":"text","label":"Date first treated_Row_1"},{"name":"Current Status of the Illness DiseasesInjuryRow4","page":3,"type":"text","label":"Current Status of the Illness/ Diseases/Injury_Row_4"},{"name":"Family Member Age","page":3,"type":"text","label":"attack, or stroke and at What age? If yes, was it before age 60 years or after 60 years"},{"name":"Group No1033","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No1033","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Member NameRow1_4","page":3,"type":"text","label":"Member Name_Row_1"},{"name":"Relationship with ProposerRow1_2","page":3,"type":"text","label":"Relationship with Proposer_Row_1"},{"name":"Disease NameRow1","page":3,"type":"text","label":"Disease Name_Row_1"},{"name":"At whatAge illness sufferedRow1.0","page":3,"type":"text","label":"At whatAge illness suffered_Row_1"},{"name":"Member NameRow2_4","page":3,"type":"text","label":"Member Name_Row_2"},{"name":"Relationship with ProposerRow2_2","page":3,"type":"text","label":"Relationship with Proposer_Row_2"},{"name":"Disease NameRow2","page":3,"type":"text","label":"Disease Name_Row_2"},{"name":"At whatAge illness sufferedRow1.1","page":3,"type":"text","label":"At whatAge illness suffered_Row_1"},{"name":"Member NameRow3_4","page":3,"type":"text","label":"Member Name_Row_3"},{"name":"Relationship with ProposerRow3_2","page":3,"type":"text","label":"Relationship with Proposer_Row_3"},{"name":"Disease NameRow3","page":3,"type":"text","label":"Disease Name_Row_3"},{"name":"At whatAge illness sufferedRow1.2","page":3,"type":"text","label":"At whatAge illness suffered_Row_1"},{"name":"Member NameRow4_3","page":3,"type":"text","label":"Member Name_Row_4"},{"name":"Relationship with ProposerRow4","page":3,"type":"text","label":"Relationship with Proposer_Row_4"},{"name":"Disease NameRow4","page":3,"type":"text","label":"Disease Name_Row_4"},{"name":"At whatAge illness sufferedRow1.3","page":3,"type":"text","label":"At whatAge illness suffered_Row_1"},{"name":"Treatment Details","page":3,"type":"text","label":"Member Name_Row_3"},{"name":"Group No20100","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No20100","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No100","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No100","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No102","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No102","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No102","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No102","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No103","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No103","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No103","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No103","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No103","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No103","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No103333","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No103333","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No103333","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No103333","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No103333","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No103333","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3","Choice3","Choice3","Choice3"]},{"name":"Group No10333333","page":3,"type":"radiobutton"},{"name":"Amount","page":3,"type":"text","label":"Amount"},{"name":"Transaction No","page":3,"type":"text","label":"Transaction No."},{"name":"TransationDate","page":3,"type":"text","label":"Date first treated_Row_10"},{"name":"Bank Name","page":3,"type":"text","label":"Bank Name"},{"name":"Branch","page":3,"type":"text","label":"Branch"},{"name":"Please provide eIA No to deposit your insurance policy","page":3,"type":"text","label":"Please provide e-IA No. to deposit your insurance policy."},{"name":"Group No105","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No105","page":3,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Name as per Bank Account","page":3,"type":"text","label":"Name as per Bank Account"},{"name":"Name of the Bank","page":3,"type":"text","label":"Name of the Bank:"},{"name":"IFSC Code","page":3,"type":"text","label":"IFSC Code:"},{"name":"Bank Account No","page":3,"type":"text","label":"Bank Account No:"},{"name":"Account Type","page":3,"type":"text","label":"Account Type:"},{"name":"Mobile No","page":3,"type":"text","label":"Mobile No:"},{"name":"Email Address","page":3,"type":"text","label":"Email Address:"},{"name":"Group No111","page":3,"type":"radiobutton"},{"name":"Group No1077777","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No1077777","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Group No1077777","page":3,"type":"radiobutton","options":["Choice3","Choice3","Choice3"]},{"name":"Date 4","page":3,"type":"text","label":"Date [2]"},{"name":"Signature Impression Of The Proposer","page":3,"type":"text","label":"sum of Rs"},{"name":"Place 4","page":3,"type":"text","label":"Place"},{"name":"Date 3","page":4,"type":"text","label":"Date [2]"},{"name":"Signature Of Intermediary","page":4,"type":"text","label":"sum of Rs"},{"name":"Signature Of Intermediary1","page":4,"type":"text","label":"sum of Rs"},{"name":"Place 3","page":4,"type":"text","label":"Place"},{"name":"Signature Of Witness","page":4,"type":"text","label":"sum of Rs"},{"name":"Name Of Witness","page":4,"type":"text","label":"sum of Rs"},{"name":"Group No11000","page":4,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No11000","page":4,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Disability Certificate","page":4,"type":"text","label":"sum of Rs"},{"name":"Name Of Authorised Representative","page":4,"type":"text","label":"sum of Rs"},{"name":"Mr./Miss/Mrs","page":4,"type":"text","label":"sum of Rs"},{"name":"Authorised Representative","page":4,"type":"text","label":"sum of Rs"},{"name":"Date 5","page":4,"type":"text","label":"Date [2]"},{"name":"Sign Of Authorised Representative","page":4,"type":"text","label":"Place"},{"name":"Place 5","page":4,"type":"text","label":"Place"},{"name":"Place 66","page":4,"type":"text","label":"Place"},{"name":"Agent Name","page":4,"type":"text","label":"sum of Rs"},{"name":"Agent Code","page":4,"type":"text","label":"sum of Rs"},{"name":"IMD Signature","page":4,"type":"text","label":"Place"},{"name":"SP / BQP / DP / PoS Name","page":4,"type":"text","label":"sum of Rs"},{"name":"SP / BQP / DP / PoS No","page":4,"type":"text","label":"sum of Rs"},{"name":"SP/BQP/DP/PoS Sign","page":4,"type":"text","label":"Place"},{"name":"Date 2","page":4,"type":"text","label":"Date [2]"},{"name":"Place 1","page":4,"type":"text","label":"Place"},{"name":"Signature Of Agent","page":4,"type":"text","label":"Place"},{"name":"Received from Ms  Mrs  Mr","page":4,"type":"text","label":"Received from Ms. / Mrs. / Mr"},{"name":"sum of Rs","page":4,"type":"text","label":"sum of Rs"},{"name":"through Cash  Cheque  DD  Credit Card  Debit Card No","page":4,"type":"text","label":"through Cash# / Cheque / DD / Credit Card / Debit Card No"},{"name":"Sign Bajaj Allianz Offical","page":4,"type":"text","label":"Bajaj Allianz Official / Intermediary Name"},{"name":"Date","page":4,"type":"text","label":"Date"},{"name":"Time","page":4,"type":"text","label":"Time"},{"name":"Place","page":4,"type":"text","label":"Place"},{"name":"Bajaj Allianz Official  Intermediary Name","page":4,"type":"text","label":"Bajaj Allianz Official / Intermediary Name"},{"name":"NameofthePolicyholderinsureds","page":5,"type":"text","label":"NameofthePolicyholder/insured(s"},{"name":"Dateof Birth Age","page":5,"type":"text","label":"Dateof Birth /Age"},{"name":"Address of policyholder insured","page":5,"type":"text","label":"Address of policyholder /insured"},{"name":"i Nameoftheproduct","page":5,"type":"text","label":"i. Nameoftheproduct"},{"name":"ii Sum Insured","page":5,"type":"text","label":"ii. Sum Insured"},{"name":"iii Cumulative Bonus","page":5,"type":"text","label":"iii. Cumulative Bonus"},{"name":"iv Add onsRiders taken","page":5,"type":"text","label":"iv. Add ons/Riders taken"},{"name":"v Policy Number","page":5,"type":"text","label":"v. Policy Number"},{"name":"i Name of the product proposedintended to take","page":5,"type":"text","label":"i. Name of the product proposed/intended to take"},{"name":"ii Sum insured proposed","page":5,"type":"text","label":"ii. Sum insured proposed"},{"name":"iii Whether CumulativeBonus to be converted toan enhanced sum insured","page":5,"type":"text","label":"iii. Whether CumulativeBonus to be converted toan enhanced sum insured"},{"name":"Reason s of portability","page":5,"type":"text","label":"Reason (s) of portability"},{"name":"Noof family member to be included in the policy tobeported","page":5,"type":"text","label":"Noof family member to be included in the policy tobeported"},{"name":"FirstNameof InsuredRow1.0","page":5,"type":"text","label":"FirstNameof Insured_Row_1"},{"name":"Details of previous health insurance policy PolicynumberRow1.0","page":5,"type":"text","label":"Details of previous health insurance policy /Policynumber_Row_1"},{"name":"HealthIdcard numberRow1.0","page":5,"type":"text","label":"HealthIdcard number_Row_1"},{"name":"Sum InsuredRow1.0","page":5,"type":"text","label":"Sum Insured_Row_1"},{"name":"CBRow1.0","page":5,"type":"text","label":"CB_Row_1"},{"name":"From ddmmyyRow1.0.0","page":5,"type":"text","label":"From dd/mm/yy_Row_1"},{"name":"To ddmmyyRow1.0.0","page":5,"type":"text","label":"To dd/mm/yy_Row_1"},{"name":"First policy inception dateRow1.0.0","page":5,"type":"text","label":"First policy inception date_Row_1"},{"name":"FirstNameof InsuredRow1.1","page":5,"type":"text","label":"FirstNameof Insured_Row_1"},{"name":"Details of previous health insurance policy PolicynumberRow1.1","page":5,"type":"text","label":"Details of previous health insurance policy /Policynumber_Row_1"},{"name":"HealthIdcard numberRow1.1","page":5,"type":"text","label":"HealthIdcard number_Row_1"},{"name":"Sum InsuredRow1.1","page":5,"type":"text","label":"Sum Insured_Row_1"},{"name":"CBRow1.1","page":5,"type":"text","label":"CB_Row_1"},{"name":"From ddmmyyRow1.0.1","page":5,"type":"text","label":"From dd/mm/yy_Row_1"},{"name":"To ddmmyyRow1.0.1","page":5,"type":"text","label":"To dd/mm/yy_Row_1"},{"name":"First policy inception dateRow1.0.1","page":5,"type":"text","label":"First policy inception date_Row_1"},{"name":"FirstNameof InsuredRow1.2","page":5,"type":"text","label":"FirstNameof Insured_Row_1"},{"name":"Details of previous health insurance policy PolicynumberRow1.2","page":5,"type":"text","label":"Details of previous health insurance policy /Policynumber_Row_1"},{"name":"HealthIdcard numberRow1.2","page":5,"type":"text","label":"HealthIdcard number_Row_1"},{"name":"Sum InsuredRow1.2","page":5,"type":"text","label":"Sum Insured_Row_1"},{"name":"CBRow1.2","page":5,"type":"text","label":"CB_Row_1"},{"name":"From ddmmyyRow1.0.2","page":5,"type":"text","label":"From dd/mm/yy_Row_1"},{"name":"To ddmmyyRow1.0.2","page":5,"type":"text","label":"To dd/mm/yy_Row_1"},{"name":"First policy inception dateRow1.0.2","page":5,"type":"text","label":"First policy inception date_Row_1"},{"name":"FirstNameof InsuredRow1.3","page":5,"type":"text","label":"FirstNameof Insured_Row_1"},{"name":"Details of previous health insurance policy PolicynumberRow1.3","page":5,"type":"text","label":"Details of previous health insurance policy /Policynumber_Row_1"},{"name":"HealthIdcard numberRow1.3","page":5,"type":"text","label":"HealthIdcard number_Row_1"},{"name":"Sum InsuredRow1.3","page":5,"type":"text","label":"Sum Insured_Row_1"},{"name":"CBRow1.3","page":5,"type":"text","label":"CB_Row_1"},{"name":"From ddmmyyRow1.0.3","page":5,"type":"text","label":"From dd/mm/yy_Row_1"},{"name":"To ddmmyyRow1.0.3","page":5,"type":"text","label":"To dd/mm/yy_Row_1"},{"name":"First policy inception dateRow1.0.3","page":5,"type":"text","label":"First policy inception date_Row_1"},{"name":"FirstNameof InsuredRow1.4","page":5,"type":"text","label":"FirstNameof Insured_Row_1"},{"name":"Details of previous health insurance policy PolicynumberRow1.4","page":5,"type":"text","label":"Details of previous health insurance policy /Policynumber_Row_1"},{"name":"HealthIdcard numberRow1.4","page":5,"type":"text","label":"HealthIdcard number_Row_1"},{"name":"Sum InsuredRow1.4","page":5,"type":"text","label":"Sum Insured_Row_1"},{"name":"CBRow1.4","page":5,"type":"text","label":"CB_Row_1"},{"name":"From ddmmyyRow1.0.4","page":5,"type":"text","label":"From dd/mm/yy_Row_1"},{"name":"To ddmmyyRow1.0.4","page":5,"type":"text","label":"To dd/mm/yy_Row_1"},{"name":"First policy inception dateRow1.0.4","page":5,"type":"text","label":"First policy inception date_Row_1"},{"name":"FirstNameof InsuredRow1.5","page":5,"type":"text","label":"FirstNameof Insured_Row_1"},{"name":"Details of previous health insurance policy PolicynumberRow1.5","page":5,"type":"text","label":"Details of previous health insurance policy /Policynumber_Row_1"},{"name":"HealthIdcard numberRow1.5","page":5,"type":"text","label":"HealthIdcard number_Row_1"},{"name":"Sum InsuredRow1.5","page":5,"type":"text","label":"Sum Insured_Row_1"},{"name":"CBRow1.5","page":5,"type":"text","label":"CB_Row_1"},{"name":"From ddmmyyRow1.0.5","page":5,"type":"text","label":"From dd/mm/yy_Row_1"},{"name":"To ddmmyyRow1.0.5","page":5,"type":"text","label":"To dd/mm/yy_Row_1"},{"name":"First policy inception dateRow1.0.5","page":5,"type":"text","label":"First policy inception date_Row_1"},{"name":"Date 2","page":5,"type":"text","label":"Date [2]"},{"name":"Signature Of Policyholder","page":5,"type":"text","label":"Place"},{"name":"Group No10660","page":5,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No10660","page":5,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Days","page":5,"type":"text","label":"No of family member to be included in the policy to be ported"},{"name":"Sign Of PolicyHolder","page":5,"type":"text","label":"Place"},{"name":"If yes please share the details","page":6,"type":"text","label":"If yes, please share the details"},{"name":"Group No55","page":6,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No55","page":6,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No555","page":6,"type":"radiobutton","options":["Choice3","Choice3"]},{"name":"Group No555","page":6,"type":"radiobutton","options":["Choice3","Choice3"]}],"fillable_pdf":true,"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/2465-global-health-care-proposal-form"}