{"id":2482,"title":"Bajaj General Individual Cyber Safe Insurance Policy (Proposal Form)","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/individual-cyber-safe-insurance/Individual-Cyber-Safe-pf.pdf","sha256":"1d012407eb5fdd06faf50090cda2b7d5161a43e8476e98ea0a71ca546bb7ae9c","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals to apply for the Bajaj General Individual Cyber Safe Insurance Policy by providing personal, family, and risk-related information.","notes":["Answer all questions fully and accurately to avoid claim rejection or policy avoidance.","Attach additional sheets if space is insufficient.","Policy cover starts only after proposal acceptance and premium payment.","Signature on behalf of proposer is required only if the proposer did not fill the form themselves.","Use the declarations and consents as applicable to individual or juridical persons.","The Insurance Act 1938 Section 41 prohibits rebates as inducements for insurance."],"title":"Bajaj General Individual Cyber Safe Insurance Policy (Proposal Form)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"","type":"text","label":"Name of the Proposer ( in full )","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender: Male Female","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Marital Status: Married Single","options":["Married","Single"],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address for Communication","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"E mail ID","options":[],"required":true,"pdf_field":""},{"help":"10 digit mobile number","type":"phone","label":"Mobile Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Education Qualification: Post Graduate & Doctorate Graduate and Graduate Students Non-Graduates","options":["Post Graduate & Doctorate","Graduate and Graduate Students","Non-Graduates"],"required":true,"pdf_field":""},{"help":"Start and end dates of insurance coverage","type":"date","label":"Period of Insurance: From: To:","options":[],"required":true,"pdf_field":""},{"help":"Select if insurance covers family members","type":"yes-no","label":"Family Floater: Yes/ No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"List family members with their age and relationship","type":"table","label":"If 9 is opted, Details of family Members to be covered Sr. No. Name Age Relationship with Proposer","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Constitution Details","fields":[{"help":"","type":"yes-no","label":"Partnership Firm","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Limited Liability/Partnership Firm","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide DARPAN registration number if applicable","type":"yes-no","label":"NGO/NPO- Provide DARPAN Portal Registration, if applicable","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Company","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Trust","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Society","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Section 8 Company","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Proprietorship Firm","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify other constitution if applicable","type":"text","label":"Others (Please specify)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance Cover Options and Limits","fields":[{"help":"Select basis of limit for cover options","type":"choice","label":"Please select Basis of Limit for the opted covers : a. Independent Sum Insured for each Cover Option b. Aggregate Policy Limit with Sub Limit for each opted Cover","options":["Independent Sum Insured for each Cover Option","Aggregate Policy Limit with Sub Limit for each opted Cover"],"required":true,"pdf_field":""},{"help":"Specify aggregate policy limit in INR","type":"amount","label":"If “b” is opted, Kindly specify Aggregate Policy Limit You want to opt","options":[],"required":false,"pdf_field":""},{"help":"For each cover option, select Yes/No and specify sum insured, deductible, sub limits, and territorial limit","type":"table","label":"Cover Options Opt for Insured Event Sum Insured (in ₹) Deductible (in ₹) Sub Limits of Aggregate Policy Limit (in %) Territorial Limit","options":[],"required":true,"pdf_field":""},{"help":"Specify daily amount and maximum days if opted","type":"text","label":"Extensions: 1. Loss of Professional Income Yes / No Rs. __ per Day up to a Maximum of ____ Days","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"2. Connected Vehicle Cover Yes / No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify amount if opted","type":"text","label":"3. Liability Arising out of Underage Children Yes / No INR. _____","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Past Incidents and Security Details","fields":[{"help":"","type":"yes-no","label":"Have you been a victim of any of the proposed covers in the past? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe past incidents if any","type":"text","label":"If answer to above question is yes, please give details","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Did you report the occurrence of the incident to the Police Authorities? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you aware at the time of proposal of any prior act, event or circumstances which is likely to give rise to a claim under any of the above insuring clauses? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Are you presently insured against cyber risk? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide existing cyber risk insurance policy details","type":"text","label":"If answer to above question is yes, give details of existing policy/policies if any","options":[],"required":false,"pdf_field":""},{"help":"Any other relevant information","type":"text","label":"Additional Information (If Any)","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Has any company/Insurer in respect of Insurance Declined your Proposal? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Cancelled or refused to renew your policy? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Accepted your proposal on special terms and conditions? Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select the authentication method used","type":"choice","label":"Level of Authentications used Multi-factor Authentication Single factor Authentication No Authentication","options":["Multi-factor Authentication","Single factor Authentication","No Authentication"],"required":true,"pdf_field":""},{"help":"Select antivirus status","type":"choice","label":"Antivirus Availability Paid Antivirus Free Antivirus No Antivirus","options":["Paid Antivirus","Free Antivirus","No Antivirus"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consents","fields":[{"help":"Politically Exposed Person declaration","type":"yes-no","label":"AML Declaration for Retail Policies/Individual Customers: Are you or any of the proposal applicants a PEP or a close relative of PEP?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if PEP","type":"text","label":"If yes, please share the details","options":[],"required":false,"pdf_field":""},{"help":"Politically Exposed Person declaration for juridical persons","type":"yes-no","label":"AML Declaration for Juridical Person/Non-Individual Customer: Are you or any of the proposal applicants a PEP or a close relative of PEP?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if PEP","type":"text","label":"If yes, please share the details","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Location of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Print name of proposer","type":"text","label":"Name","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Individual Cyber Safe Insurance Policy proposals","attachments":["Attach a separate sheet if there is insufficient space to provide relevant information"],"declarations":["The statements made in the proposal are true, accurate, and complete and form the basis of the insurance contract.","The policy will be void if any untrue or incorrect statement, misrepresentation, or non-disclosure is made.","Policy issuance is subject to realization of premium payment.","Consent is given to share personal information with group companies for insurance and related services.","AML declarations and consents regarding Politically Exposed Persons and KYC verification are agreed to.","Premiums are declared to be paid from legally acquired sources of income."],"dropped_labels":9},"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/2482-bajaj-general-individual-cyber-safe-insurance-policy-proposal-form"}