{"id":2473,"title":"HEALTH GUARD (GROUP) : PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/health-guard-group/Group_HG_PF.pdf","sha256":"d922f8a571bdc7621217a9d4c5236df4e9fe70e882e3366273b2c5e637f504b5","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a group health insurance proposal form to be filled by the proposer representing a bank, financial institution, or group whose members are to be insured.","notes":["Please answer all questions in BLOCK letters.","Liability of the company starts only after acceptance of proposal and payment of premium.","Provide all information fully and accurately including additional information relevant to risk.","Attach list of persons to be covered as per attached format.","Nominee for self (employee/member) must be one of the specified relations; if 'Others', specify relationship and reason.","Use original documents where required.","This form and particulars must be explained in vernacular language if proposer does not understand English.","BIMA ASBA declaration applies only if premium payment is through online payment mode.","Submission of proposal or payment does not oblige the company to issue a policy; decision is at company's sole discretion."],"title":"HEALTH GUARD (GROUP) : PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Enter full name of the proposer organization","type":"text","label":"Name of the Proposer (in full)","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN or TAN number of the proposer","type":"text","label":"PAN/TAN no.","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E mail ID","options":[],"required":true,"pdf_field":""},{"help":"Describe the business of the proposer","type":"text","label":"Description of the Proposer's Business","options":[],"required":true,"pdf_field":""},{"help":"Provide details of the bank/financial institution/group","type":"text","label":"Please mention detail of the Bank/ Financial Institution / Group whose members are being covered under the Policy?","options":[],"required":true,"pdf_field":""},{"help":"Select the plan opted","type":"choice","label":"Plan Opted","options":["Silver","Gold"],"required":true,"pdf_field":""},{"help":"Select 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":""},{"help":"Enter total number of persons to be covered","type":"number","label":"Please mention the Total number of persons to be covered:","options":[],"required":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Have you provided complete details of members in Annexure I?","options":["YES","NO"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Annexure I - List of Persons Proposed for Insurance","fields":[{"help":"Fill details for each insured person: Sr. No., Name of the Insured, ABHA Number (14 Digits), Employee Code/Account No (if applicable), Relationship of dependent members to Employee/Member, DOB (DD-MM-YYYY), Gender, Height (cms), Weight (kgs), Sum Insured (Floater), Nominee, Nominee Relationship with Insured, Appointee (If nominee is minor), Pre-Existing Disease (if any)","type":"table","label":"LIST OF PERSONS PROPOSED FOR INSURANCE","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"ABHA Declaration","fields":[{"help":"Tick if you consent to ABHA data access","type":"checkbox","label":"I/We provide my/ our consent to access my/ our (all insured) medical and personal records/ details, as are available in my/ our Ayushman Bharat Health Account (ABHA) and sole purposes of underwriting my/ our proposal and/ or for checking the authenticity of claims lodged by me/ us and/ or to comply with the applicable Law/ Regulations","options":["I/We provide my/our consent"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Rider and Plan Options","fields":[{"help":"Select yes or no; rider available for sum insured INR 5,00,000 and above with extra premium","type":"choice","label":"Non-Medical Expenses Cover (Rider)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify plan option","type":"text","label":"Health Prime Ride(Group) Individual Floater Plan Option","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Health and Medical History","fields":[{"help":"Provide details of consumption and duration","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":""},{"help":"Provide details if yes","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":""},{"help":"Select 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":true,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Have you or any of the persons proposed to be insured were/are detected as Covid positive?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Select yes or no and provide details if yes","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? (Please provide details in the table given below)","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Fill Member Name, Name of the Illness/injury suffered/suffering in the past, Treatment details, Date first treated, Current Status of the Illness/Diseases/Injury","type":"table","label":"If the reply is YES for question 13 to 15 please share details in below table","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no","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":true,"pdf_field":""},{"help":"Select applicable age group","type":"choice","label":"If yes, was it before age 60 years or after 60 years?","options":["Before 60 years","After 60 years"],"required":false,"pdf_field":""},{"help":"Provide details of family members with diseases","type":"table","label":"Member Name, Relationship with Proposer, Disease Name, At what Age illness suffered","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select mode of payment","type":"choice","label":"Payment Mode","options":["Cash","Cheque","DD","Credit Card","Debit","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":"Enter premium amount","type":"amount","label":"Amount","options":[],"required":true,"pdf_field":""},{"help":"Enter transaction number for online payments","type":"text","label":"Transaction No.","options":[],"required":false,"pdf_field":""},{"help":"Enter transaction date","type":"date","label":"Transaction Date","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":false,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"Provide e-IA number to deposit insurance policy","type":"text","label":"Electronic-Insurance Account","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Do you want to open e-IA account","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter name as per bank account","type":"text","label":"Bank Details: Name as per Bank Account","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No","options":[],"required":false,"pdf_field":""},{"help":"Enter account type","type":"text","label":"Account Type","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile No","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email Address","options":[],"required":false,"pdf_field":""},{"help":"Select preferred contact mode","type":"choice","label":"In case of any Offer, you would prefer to be contacted by","options":["Phone","Email","WhatsApp"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Sign or provide thumb impression","type":"signature","label":"Signature/ Thumb Impression of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Signature of agent or intermediary","type":"signature","label":"Signature of Intermediary","options":[],"required":true,"pdf_field":""},{"help":"Enter witness name","type":"text","label":"Name of Witness","options":[],"required":false,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"Select yes or no","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":""},{"help":"Enter name of authorized representative","type":"text","label":"Name of Authorised Representative","options":[],"required":false,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Signature of authorized representative","type":"signature","label":"Signature of Authorised Representative","options":[],"required":false,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer or authorized representative"},{"title":"Agent Details and Declaration","fields":[{"help":"Enter agent or IMD name","type":"text","label":"Agent/IMD Name","options":[],"required":true,"pdf_field":""},{"help":"Enter agent or IMD code","type":"text","label":"Agent/IMD Code","options":[],"required":true,"pdf_field":""},{"help":"Agent signature","type":"signature","label":"Agent/IMD Signature","options":[],"required":true,"pdf_field":""},{"help":"Enter SP/BQP/DP/PoS name","type":"text","label":"SP / BQP / DP / PoS Name","options":[],"required":false,"pdf_field":""},{"help":"Enter CoR number","type":"text","label":"SP / BQP / DP / PoS CoR No.","options":[],"required":false,"pdf_field":""},{"help":"Signature of SP/BQP/DP/PoS","type":"signature","label":"SP / BQP / DP / PoS Signature","options":[],"required":false,"pdf_field":""},{"help":"Agent declares having explained the form contents to proposer","type":"text","label":"Agent Declaration","options":[],"required":true,"pdf_field":""},{"help":"Date of agent declaration","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Agent signature","type":"signature","label":"Signature of Agent","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"},{"title":"PEP and KYC Declarations","fields":[{"help":"Select 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":""},{"help":"Select yes or no","type":"yes-no","label":"I/we hereby give my/our consent to the Company to verify and obtain my/our identity/address proof through Central KYC Registry or Goods and Service Tax Portal or Ministry Of Corporate Affairs Portal or National Securities Depository Limited portal for the purpose of undertaking KYC.","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"I/we hereby agree and ensure to maintain details of all the beneficiaries covered under the policy and shall share the same with the Company as and when required.","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Group health insurance policies for banks, financial institutions, or groups","attachments":["List of persons to be covered as per the format attached","Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability (if applicable)","Additional sheets if space not sufficient to complete details"],"declarations":["The statements and particulars given are true and complete to the best of the proposer's knowledge and the proposer is authorized to propose on behalf of others.","The policy will come into force only after full payment of premium and acceptance by the company.","The proposer will notify any change in occupation or health after submission but before acceptance.","The company may seek medical information from doctors, hospitals, employers, or insurers for underwriting or claim settlement.","Consent is given to the company to collect and share personal and medical information from Ayushman Bharat Health Account (ABHA) with reinsurers, service providers, and regulatory authorities for underwriting and claims.","Agent declares having explained the proposal form contents to the proposer in vernacular language if required.","Non-disclosure or untrue statements may lead to policy variation or nullification and forfeiture of premiums.","No rebates or inducements are allowed except as per published prospectus or tables; violation is punishable by fine.","Consent to share personal information with group companies or others for insurance policy or related services."],"dropped_labels":1},"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/2473-health-guard-group-proposal-form"}