{"id":2475,"title":"Assignment Declaration","purpose":"service","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/Assignment-Declaration-Form.pdf","sha256":"ef1830c4a9919f22ec6ba6ca8ad24a255270eb1cdeb8a7b6b783c42a321e8225","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the policyholder (assignor) to transfer their rights and benefits under an insurance policy to another person (assignee). Both the assignor and assignee must fill and sign the form.","notes":["Form must be duly filled and signed by the insured and the assignee","Depending on assignment type, delete or strike off inapplicable clauses and counter sign them","Parties should satisfy themselves before forwarding the policy document to Bajaj General Insurance Limited","This form shall be accompanied by the original policy document","Assignment of a policy automatically cancels any nomination except as specified","Use original policy number and product name as applicable"],"title":"Assignment Declaration","submit":{"to":"Bajaj General Insurance Company Limited","how":"","address":"Bajaj Insurance House, Airport Road, Yerawada, Pune - 411006"},"purpose":"service","sections":[{"title":"Policy and Contact Details","fields":[{"help":"","type":"text","label":"Product Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy holder’s Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Provide phone number or other contact info","type":"text","label":"Contact Details","options":[],"required":null,"pdf_field":""},{"help":"Provide a valid email address","type":"email","label":"Email Id:","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Assignment Options and Declarations","fields":[{"help":"Select one assignment type by ticking the box and delete/strike off the other clauses as applicable","type":"choice","label":"Please tick (✓) for whichever is applicable and (✗) for whichever is not applicable","options":["1. Full Assignment","2. Partial Assignment","3. Conditional Assignment"],"required":true,"pdf_field":""}],"filled_by":"policyholder and assignee"},{"title":"Assignee Details","fields":[{"help":"Full name of the person receiving the assignment","type":"text","label":"Name of the Assignee","options":[],"required":true,"pdf_field":""},{"help":"Complete postal address of the assignee","type":"text","label":"Address with Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Phone number of the assignee","type":"phone","label":"Contact Number","options":[],"required":true,"pdf_field":""},{"help":"Relationship of assignee to the policyholder","type":"text","label":"Relationship with Insured","options":[],"required":true,"pdf_field":""},{"help":"Assignee must sign here","type":"signature","label":"Signature of Assignee","options":[],"required":true,"pdf_field":""},{"help":"Date and place of signing","type":"date","label":"Date and Place","options":[],"required":true,"pdf_field":""}],"filled_by":"assignee"},{"title":"Witness Details","fields":[{"help":"Full name of second witness","type":"text","label":"Witness 2 Name","options":[],"required":true,"pdf_field":""}],"filled_by":"witnesses"},{"title":"Assignor Signature and Execution","fields":[{"help":"Policyholder must sign here","type":"signature","label":"Signature of Assignor (Insured)","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Executed on: Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"assignor (insured)"}],"deadlines":[],"applies_to":"","attachments":["Original policy document in respect of which the assignment is made"],"declarations":["Assignment is irrevocable and cannot be transferred to others except the named assignee","Assignment cancels any nomination made in the policy except when assigned to Bajaj General Insurance Company Limited","Assignee’s receipt of rights and benefits is subject to all rights and liabilities of the insured","Assignment is governed by provisions of section 38 of the Insurance Act 1938","Assignor agrees that legal heirs and nominees are bound by this assignment and their rights are subject to assignee’s rights"],"dropped_labels":14},"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/2475-assignment-declaration"}