{"id":2483,"title":"EXTENDED WARRANTY PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/extended-warranty/Extended-Warranty-pf.pdf","sha256":"92f14e77ca7a6a48ff371550a947425f67feb07608e44856f53718dd865d150c","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer to apply for an extended warranty insurance policy for specified items. The proposer fills this form.","notes":["Please answer all questions in BLOCK letters.","Sum insured for an item should represent its original purchase price.","This proposal form must be accepted by the company and full premium paid before liability commences.","Use original and accurate information; any false or misleading information may void the policy.","If the proposal form is not filled by the proposer, the person explaining must certify the contents have been explained and understood.","Politically Exposed Persons (PEPs) must be declared with details.","Keep policy contact details updated via app, WhatsApp, call center, website, agent or branch.","Section 41 of Insurance Act, 1938 prohibits rebates on commission or premium except as allowed.","The form includes a confidentiality and disclaimer notice regarding email communications."],"title":"EXTENDED WARRANTY PROPOSAL FORM","submit":{"to":"Bajaj General Insurance Limited","how":"","address":"Bajaj Insurance House, Airport Road, Yerawada, Pune - 411006"},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"Write your full name in BLOCK letters","type":"text","label":"Name of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Write your full residential address","type":"text","label":"Residential Address","options":[],"required":true,"pdf_field":""},{"help":"Provide your telephone number","type":"phone","label":"Telephone No.","options":[],"required":false,"pdf_field":""},{"help":"Provide your mobile number","type":"phone","label":"Mobile Number","options":[],"required":true,"pdf_field":""},{"help":"Provide your email address","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Bank Details","fields":[{"help":"Provide the name as per bank records","type":"text","label":"Name as pr Bank","options":[],"required":false,"pdf_field":""},{"help":"Provide your bank's name","type":"text","label":"Name Of Bank","options":[],"required":false,"pdf_field":""},{"help":"Provide your bank account number","type":"text","label":"Bank Account No.","options":[],"required":false,"pdf_field":""},{"help":"Provide your bank branch IFSC code","type":"text","label":"IFSCCode","options":[],"required":false,"pdf_field":""},{"help":"Tick to accept payment and receipt of claim amount in the above bank account","type":"checkbox","label":"* I accept to pay & receive claim amount (if any) in the above given Bank a/c","options":["accept"],"required":true,"pdf_field":""},{"help":"Provide your e-Insurance Account number if available","type":"text","label":"Electronic-Insurance Account: Please provide e-lA No. to deposite your insurance policy.","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Do you want to open e-lA account","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Existing Customer Details","fields":[{"help":"Select Yes or No","type":"choice","label":"Are you an exisiting customer of BGIL ?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide IFSC code if existing customer","type":"text","label":"IFSCCode","options":[],"required":false,"pdf_field":""},{"help":"Provide PID or Policy number if existing customer","type":"text","label":"If Yes. Please provide PID No: /Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Tick to confirm no change in KYC details","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":["confirm"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Item Details","fields":[{"help":"Fill details for each item to be insured; sum insured should be original purchase price","type":"table","label":"Details of Items to be Insured (Description of the equipment, Name and Make, Year of manufacture and Model, Date of Purchase, Address of the Seller, Period of Manufacturer's Warranty From/To, Sum Insured (in Rs.), Deductible Opted For Partial Loss Yes/No)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposed Policy Period and Premium Details","fields":[{"help":"Enter net premium amount","type":"amount","label":"Net Premium","options":[],"required":true,"pdf_field":""},{"help":"Enter service tax amount","type":"amount","label":"Service Tax","options":[],"required":true,"pdf_field":""},{"help":"Enter total premium amount","type":"amount","label":"Total Premium","options":[],"required":true,"pdf_field":""},{"help":"Provide cheque number if paying by cheque","type":"text","label":"Mode of Payment a) By Cheque: Cheque No.","options":[],"required":false,"pdf_field":""},{"help":"Provide bank name for cheque payment","type":"text","label":"Bank","options":[],"required":false,"pdf_field":""},{"help":"Provide bank branch for cheque payment","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance History","fields":[{"help":"Select Yes or No","type":"choice","label":"Has any General Insurance Company, in respect of the risk to which this proposal relates, ever: Declined a proposal, refused renewal or terminated insurance?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Required an increased premium or imposed special conditions?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details if answered Yes above","type":"text","label":"If yes in either case, please provide details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration and Warranty","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Print your name","type":"text","label":"Name","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration by Person Explaining the Form (if not filled by Proposer)","fields":[{"help":"Enter place","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature (on behalf of Proposer)","options":[],"required":false,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Print name","type":"text","label":"Name","options":[],"required":false,"pdf_field":""}],"filled_by":"person explaining"},{"title":"Declaration - Physical Proposal Form","fields":[{"help":"Select Yes or No","type":"choice","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":"choice","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":"choice","label":"I/we hereby declare and confirm that the premium has been paid out of legally acquired sources of income and the subsequent premiums if any, will continue to be paid out of legally declared and assessed source of income.","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"I/We hereby give voluntary consent to BGIL/Company to share my/our personal information and data provided in this proposal form with its group companies or any other person in connection with the Insurance Policy or otherwise","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"It is mandatory to keep your policy with updated contact (Mobile No., Email ID and PAN Card) and bank account details, to process any of your service requests faster and hassle-free in future.","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Print 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":""},{"help":"Date of witness signature","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Place of witness signature","type":"text","label":"Place","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Disability Declaration","fields":[{"help":"Select Yes or No","type":"choice","label":"Any Physical deformity or handicap","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":"If proposer is disabled, authorized representative's name","type":"text","label":"Name of Authorised Representative","options":[],"required":false,"pdf_field":""},{"help":"Signature of authorized representative","type":"signature","label":"Signature of Authorised representative","options":[],"required":false,"pdf_field":""},{"help":"Date of signature","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Place of signature","type":"text","label":"Place","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Claim Documents Declaration","fields":[{"help":"Tick to confirm all required documents have been provided","type":"checkbox","label":"I/we hereby confirm that I/we have provided all relevant and supporting documents sought by the company, required for the issuance of the policy.","options":["confirm"],"required":true,"pdf_field":""},{"help":"Tick to agree to submit documents on demand for claims","type":"checkbox","label":"Any document(s) as may be required, for claims processing, shall be submitted by me on demand by the company.","options":["agree"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent/Intermediary Declaration","fields":[{"help":"Provide agent license number","type":"text","label":"IRDAI COR No./ License No.(Advisor/Corporate Agent/Broker/Relationship Officer)","options":[],"required":true,"pdf_field":""},{"help":"Agent signs here","type":"signature","label":"Signature of Agent","options":[],"required":true,"pdf_field":""},{"help":"Date of agent signature","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of agent signature","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Provide agent/IMD signature and code","type":"text","label":"Agent / IMD (SP/DP/ BQP) signature and their code","options":[],"required":false,"pdf_field":""},{"help":"SP/BQP/DP/PoS name","type":"text","label":"SP/ BQP /DP/ PoS Name","options":[],"required":false,"pdf_field":""},{"help":"SP/BQP/DP/PoS CoR number","type":"text","label":"SP/ BQP /DP/ PoS CoR No.","options":[],"required":false,"pdf_field":""},{"help":"SP/BQP/DP/PoS signature","type":"signature","label":"SP/ BQP /DP/ PoS Signature","options":[],"required":false,"pdf_field":""}],"filled_by":"agent"}],"deadlines":[],"applies_to":"Extended warranty insurance policies for items after the expiry of the manufacturer's warranty","attachments":["Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability (if applicable)"],"declarations":["The information provided in this proposal form is complete, true and accurate to the best of the proposer's knowledge.","The proposal form and declaration form the basis of the insurance contract if accepted by the company.","The insurance contract is effective only upon company acceptance and receipt of full premium.","The proposer agrees to inform the company of any material changes after submission of this proposal.","The proposer undertakes to exercise reasonable precautions for safety of the insured property.","No person shall offer or accept any rebate of commission or premium except as allowed by insurer's published prospectus.","The proposer consents to verification of identity/address through specified government portals for KYC.","The proposer confirms premiums are paid from legally acquired sources.","The proposer consents to sharing personal information with group companies for insurance and related services.","The proposer agrees to keep policy contact and bank details updated for faster service.","The proposer confirms all required documents for policy issuance have been provided and will submit claim documents on demand.","The agent/intermediary declares having explained the proposal form contents to the proposer in their vernacular language."],"dropped_labels":8},"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/2483-extended-warranty-proposal-form"}