{"id":2489,"title":"CLINICAL TRIAL LIABILITY INSURANCE POLICY (Legal Liability) PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/clinical-trial-liability-policy-legal-liability/Clinical-Trial-Legal-Liability-pf.pdf","sha256":"6c8510b640e836491573094e0d46ee6c5d237018b073ff6d23055617e3f1c546","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by companies or bodies seeking insurance coverage for clinical trial liability. The proposer (company or body to be insured) fills it.","notes":["Use typed answers preferably or complete in ink.","All questions must be answered to get a quotation.","Attach additional sheets on headed paper if space is insufficient.","Disclose all material facts to the insurer.","Keep policy contact and bank details updated via app, WhatsApp, call center, SMS, email, website, agent or branch."],"title":"CLINICAL TRIAL LIABILITY INSURANCE POLICY (Legal Liability) PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Company and Trial Details","fields":[{"help":"","type":"text","label":"Name of Company or Body to be insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Description of Business","options":[],"required":null,"pdf_field":""},{"help":"Format: date of establishment","type":"date","label":"Date Established","options":[],"required":null,"pdf_field":""},{"help":"Start date of the clinical trial","type":"date","label":"Start date","options":[],"required":null,"pdf_field":""},{"help":"End date of the clinical trial","type":"date","label":"End Date","options":[],"required":null,"pdf_field":""},{"help":"Specify which form is required and attach compensation agreement if applicable","type":"text","label":"Form required- Legal Liability or No fault Compensation, IF no fault compensation then please provide Compensation agreement/basis.","options":[],"required":null,"pdf_field":""},{"help":"Total number of patients in the clinical trials","type":"number","label":"Total No. of Patients participating in the studies.","options":[],"required":null,"pdf_field":""},{"help":"Attach patient consent forms","type":"attachment","label":"Patient Consent Forms","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Constitution Details","fields":[{"help":"Answer yes or no for each item below","type":"yes-no","label":"Are all trials conducted in full accordance with:","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Department of Health requirements with protocols approved by an independent Ethics Committee?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Royal College of Physicians recommendations?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Applicable Government Department or Medical Body or Pharmaceutical Industry Body guidelines?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"E.C. guidelines on Good Clinical Practice?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"I.C.H. Harmonised Tripartite Guidelines?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"If applicable, are all rights of recourse retained against Trial Sponsors and/or Product Manufacturers?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select the constitution type and specify if 'Others'","type":"choice","label":"Constitution Details","options":["Partnership Firm","Limited Liability/Partnership Firm","NGO/NPO","Company","Trust","Society","Section 8 Company","Proprietorship Firm","Others (Please specify)"],"required":null,"pdf_field":""},{"help":"Provide DARPAN Portal Registration if applicable","type":"text","label":"DARPAN DETAILS","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Clinical Trial History and Details","fields":[{"help":"Provide full details of adverse events and claims","type":"text","label":"Give details of serious adverse events during the last 5 years resulting in death, disease or illness (physical or mental) to research subjects, and any circumstances, which have given or might give rise to a claim against you.","options":[],"required":null,"pdf_field":""},{"help":"Describe the clinical trials planned","type":"text","label":"Full description of Clinical Trials to be conducted","options":[],"required":null,"pdf_field":""},{"help":"Attach the listed documents for each trial","type":"attachment","label":"For each trial please attach a copy of: (a) PROTOCOL (or summary thereof) or ETHICS COMMITTEE SUBMISSION (b) VOLUNTEER CONSENT FORM AND/OR PATIENT INFORMATION (as appropriate) (c) ANY HOLD HARMLESS AGREEMENT/CONTRACT INDEMNITIES WITH OTHER PARTIES (if applicable)","options":[],"required":null,"pdf_field":""},{"help":"Fill the table with details of trials performed in last 12 months","type":"table","label":"SUMMARY OF TRIALS PERFORMED IN THE LAST 12 MONTHS: Date Commenced, Trial Title / Description, Phase, No. Of Research Subjects, Current Status","options":[],"required":null,"pdf_field":""},{"help":"Fill the table with details of trials planned in next 12 months","type":"table","label":"SUMMARY OF TRIALS PLANNED IN THE NEXT 12 MONTHS: Date Commenced, Trial Title / Description, Phase, No. Of Research Subjects, Sponsor","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance Coverage and Declaration","fields":[{"help":"Specify indemnity limit per clinical trial subject","type":"amount","label":"Please state Limits of Indemnity for which a quotation is required or local currency equivalent: Per each Clinical trial Subject","options":[],"required":null,"pdf_field":""},{"help":"Specify total coverage amount per annum","type":"amount","label":"Total coverage Per annum","options":[],"required":null,"pdf_field":""},{"help":"Specify higher limits if required","type":"amount","label":"If higher, please state","options":[],"required":false,"pdf_field":""},{"help":"Signature of the person completing the form","type":"signature","label":"Signed","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Additional Declarations and Consents","fields":[{"help":"PEP means Politically Exposed Persons as defined","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":null,"pdf_field":""},{"help":"Consent for KYC verification","type":"checkbox","label":"I/we hereby give my/our consent to the Company to verify and obtain my/our identity/address proof through CERSAI records or National Securities Depository Limited Portal for the purpose of undertaking KYC verification.","options":["Yes"],"required":null,"pdf_field":""},{"help":"Declaration of legal source of premium payment","type":"checkbox","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"],"required":null,"pdf_field":""},{"help":"Consent to share personal information","type":"yes-no","label":"I/We hereby give voluntary consent to Bajaj General/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, including for providing products and services of group companies that may be of interest to me/us, to be used in accordance with their respective privacy policies and subject to appropriate measures being in place to safeguard my/our personal information.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Clinical Trial Liability Insurance Policy (Legal Liability)","attachments":["Protocol Details of the studies","Patient Consent Forms","Compensation agreement/basis if no fault compensation form is required","PROTOCOL (or summary thereof) or ETHICS COMMITTEE SUBMISSION for each trial","VOLUNTEER CONSENT FORM AND/OR PATIENT INFORMATION for each trial","ANY HOLD HARMLESS AGREEMENT/CONTRACT INDEMNITIES WITH OTHER PARTIES (if applicable)"],"declarations":["The answers to this form preferably should be typed, or alternatively completed in ink.","All questions must be answered; if not, no quotation will be given.","Completion and signature of this form does not bind the Proposer or Underwriter to complete a contract of insurance.","If you have insufficient space to complete any of your answers, please continue on your headed paper and attach to this form.","It is your duty to disclose all material facts to Insurers.","No person shall allow or offer any rebate as an inducement to take or renew insurance except as allowed by the insurer's published prospectus or tables.","Penalty for non-compliance with rebate prohibition may extend to ten lakhs rupees.","It is mandatory to keep your policy with updated contact and bank account details to process service requests faster."],"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/2489-clinical-trial-liability-insurance-policy-legal-liability-proposal-form"}