{"id":2470,"title":"Family Health Care:  PROPOSAL FORM (without Pre-Policy Medical Check Up)","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/digital-pf/family-health-care-PF-gold-without-PPC-Final.pdf","sha256":"c16c82a27d6d9eabc5944ce0e57da787bd85287498a8d7bd68fcfdf9cfb702cb","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for a family health insurance policy to be filled by the proposer who wishes to insure themselves and their family members.","notes":["Answer all questions in BLOCK letters","Liability of the company starts only after acceptance and premium payment","Attach list of persons to be covered as per the attached format","Attach additional sheets if space is insufficient","Use original documents and provide accurate information","Read declaration carefully before signing"],"title":"Family Health Care:  PROPOSAL FORM (without Pre-Policy Medical Check Up)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Write your full name in BLOCK letters","type":"text","label":"Name of the Proposer (in full)","options":[],"required":true,"pdf_field":"Text1.0"},{"help":"Provide your PAN or TAN number","type":"text","label":"PAN/TAN no.","options":[],"required":false,"pdf_field":"Text1.1"},{"help":"Write your full address","type":"text","label":"Address","options":[],"required":true,"pdf_field":"Text1.2"},{"help":"Write your state","type":"text","label":"State","options":[],"required":true,"pdf_field":"Text1.3"},{"help":"Write your postal pin code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":"Text1.4"},{"help":"Write your email address","type":"email","label":"E mail ID","options":[],"required":false,"pdf_field":"Text1.5"},{"help":"Describe your business or occupation","type":"text","label":"Description of the Proposer's Business","options":[],"required":false,"pdf_field":"Text1.6"},{"help":"Provide details of the bank or group members covered","type":"text","label":"Please mention detail of the Bank/ Financial Institution / Group whose members are being covered under the Policy?","options":[],"required":false,"pdf_field":"Text1.7"},{"help":"Select the plan you want to opt for","type":"choice","label":"Plan Opted      Silver     Gold","options":["Silver","Gold"],"required":true,"pdf_field":"Group1"},{"help":"Answer YES or NO","type":"yes-no","label":"Please state whether all eligible members of the Bank/ Financial Institution / Group are proposed for Insurance?","options":["YES","NO"],"required":true,"pdf_field":"Group2"},{"help":"Write total number of persons to be insured","type":"number","label":"Please mention the Total number of persons to be covered:","options":[],"required":true,"pdf_field":"Text1.8"}],"filled_by":"proposer"},{"title":"List of Persons Proposed for Insurance","fields":[{"help":"Answer YES or NO","type":"yes-no","label":"Have you provided complete details of members in Annexure I?","options":["YES","NO"],"required":true,"pdf_field":"Group3"}],"filled_by":"proposer"},{"title":"Health and Medical Information","fields":[{"help":"Answer YES or NO and provide ABHA number if YES","type":"yes-no","label":"Are you or any of your family members registered under the Ayushmaan Bharat Yojana? If yes please share your Ayushmaan Bharat Health Account Number (ABHA) in the below table","options":["YES","NO"],"required":false,"pdf_field":"Group4"},{"help":"Provide 14 digit ABHA number","type":"text","label":"ABHA Number (14 Digits)","options":[],"required":false,"pdf_field":"Text2.5.0"},{"help":"Describe your consumption habits with duration and daily amount","type":"text","label":"Do you smoke cigarettes or consume tobacco (chewing paste) / alcohol, nicotine or marijuana in any form? Please give duration and daily consumption?","options":[],"required":false,"pdf_field":"Text2.5.1"},{"help":"Answer YES or NO","type":"yes-no","label":"Have you or any of the persons proposed to be insured were/are detected as Covid positive?","options":["YES","NO"],"required":false,"pdf_field":"Group5"},{"help":"Answer YES or NO","type":"yes-no","label":"Has any of the persons to be insured suffer from/or investigated for any of the following? Disorder of the heart, or circulatory system, chest pain, high blood pressure, stroke, asthma any respiratory conditions, cancer tumor lump of any kind, diabetes, hepatitis, disorder of urinary tract or kidneys, blood disorder, any mental or psychiatric conditions, any disease of brain or nervous system, fits (epilepsy) slipped disc, backache, any congenital/ birth defects/ urinary diseases, AIDS or positive HIV.","options":["YES","NO"],"required":false,"pdf_field":"Group6"},{"help":"Provide details if applicable","type":"text","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":[],"required":false,"pdf_field":"Text2.5.2"},{"help":"Fill details for each member: Member Name, Name of Illness/Injury, Treatment details, Date first treated, Current status, Vaccinated against COVID-19 (Yes/No)","type":"table","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? (Please provide details in the table given below)","options":[],"required":false,"pdf_field":"Text5.0.1"},{"help":"Provide details of family medical history","type":"text","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":[],"required":false,"pdf_field":"Text2.5.3"}],"filled_by":"proposer"},{"title":"Additional Options","fields":[{"help":"Specify plan option if applicable","type":"text","label":"Health Prime Ride(Group) Individual Floater Plan Option","options":[],"required":false,"pdf_field":"Text3.1.0"},{"help":"Select Yes or No for rider","type":"yes-no","label":"Non-Medical Expenses Cover (Rider) Yes No","options":["Yes","No"],"required":false,"pdf_field":"Group7"}],"filled_by":"proposer"},{"title":"Payment Details and Acknowledgement","fields":[{"help":"Write full name of proposer","type":"text","label":"Received from Ms. / Mrs. / Mr:","options":[],"required":true,"pdf_field":"Text6.0"},{"help":"Write amount paid","type":"amount","label":"Sum of Rs.","options":[],"required":true,"pdf_field":"Text6.1"},{"help":"Signature of official or intermediary","type":"signature","label":"Signature of Bajaj General Official/ Intermediary","options":[],"required":true,"pdf_field":"Text6.2"},{"help":"Date of signature","type":"date","label":"Date","options":[],"required":true,"pdf_field":"Text6.3.0"},{"help":"Time of signature","type":"text","label":"Time","options":[],"required":false,"pdf_field":"Text6.3.1.0"},{"help":"Place of signature","type":"text","label":"Place","options":[],"required":false,"pdf_field":"Text6.3.1.1"}],"filled_by":"proposer and Bajaj General Official/Intermediary"},{"title":"Declarations and Consent","fields":[{"help":"Sign or put thumb impression","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":"Text6.3.1.2"},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":"Text6.3.1.3"},{"help":"Agree to all declarations before signing","type":"checkbox","label":"Declaration*","options":["I declare that the information given is true and complete","I consent to medical information being sought","I will notify changes in occupation or health","I authorize use of ABHA data for underwriting and claims"],"required":true,"pdf_field":"Group9"},{"help":"Answer if you or relatives are Politically Exposed Persons","type":"yes-no","label":"Are you or any of the proposal applicants a PEP* or a close relative of PEP*? If yes, please share the details","options":["Yes","No"],"required":false,"pdf_field":"Group10"}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Family Health Care Policy Proposal","attachments":["List of persons to be covered as per the format attached","Additional sheets if space is insufficient to complete details"],"declarations":["The information provided is true and complete to the best of the proposer's knowledge","The company may seek medical information from doctors, hospitals, or insurers for underwriting and claims","The policy will commence only after acceptance and full premium payment","The proposer will notify any change in occupation or health after submission and before acceptance","Consent is given to use and share ABHA data for underwriting and claims","No rebates or inducements are allowed as per Insurance Act 1938","Consent is given for KYC verification through official portals","The proposer agrees to maintain and share beneficiary details as required","Consent may be given to share personal data with group companies for 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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. 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