{"id":2491,"title":"Bajaj General Protect Platinum II Directors & Officers Liability and Company Reimbursement Policy PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/commercial-general/Protect-Platinum-II-pf.pdf","sha256":"2001d91a8b28337981637644674af47eec6527d35b6622164eb8419a0d509e56","pages":8,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for insurance under the Directors & Officers Liability and Company Reimbursement Policy, to be filled by the company seeking insurance.","notes":["Answer all questions fully and accurately; attach separate sheets if space is insufficient.","Use original and latest documents as required.","Keep policy updated with contact and bank details for faster service.","Politically Exposed Persons (PEPs) must disclose status and details.","Disability declaration requires supporting certificate if applicable.","Agent/intermediary must sign and provide license details.","The form is a physical proposal form and must be signed by authorised persons and witnesses."],"title":"Bajaj General Protect Platinum II Directors & Officers Liability and Company Reimbursement Policy PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Company Details and Bank Information","fields":[{"help":"","type":"text","label":"Name of Company","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Nature of Business","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place of Incorporation","options":[],"required":true,"pdf_field":""},{"help":"Provide duration in years or relevant format","type":"text","label":"How long has the company continuously been in business?","options":[],"required":true,"pdf_field":""},{"help":"Provide bank details as per bank records","type":"text","label":"Bank Details","options":[],"required":true,"pdf_field":""},{"help":"Name as per bank records","type":"text","label":"Name as pr Bank","options":[],"required":true,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name Of Bank","options":[],"required":true,"pdf_field":""},{"help":"Provide bank account number","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"Provide IFSC code of the bank branch","type":"text","label":"IFSCCode","options":[],"required":true,"pdf_field":""},{"help":"Tick to accept","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 e-lA 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":""},{"help":"Select Yes or No","type":"choice","label":"Are you an exisiting customer of Bajaj General?","options":["Yes","No"],"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","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":"company"},{"title":"Company Changes in Past Five Years","fields":[{"help":"Select the constitution type or specify if Others","type":"choice","label":"If Yes Specify Constitution","options":["Partnership Firm","Limited Liability/Partnership Firm","NGO/NPO - Provide DARPAN Portal Registration, if applicable","Company","Trust","Society","Section 8 Company","Proprietorship Firm","Others (Please specify)"],"required":false,"pdf_field":""},{"help":"Provide details if Others selected","type":"text","label":"Constitution Details","options":[],"required":false,"pdf_field":""},{"help":"Provide DARPAN Portal Registration if applicable","type":"text","label":"DARPAN DETAILS","options":[],"required":false,"pdf_field":""}],"filled_by":"company"},{"title":"Company Auditor, Acquisitions, Mergers and Plans","fields":[{"help":"Select Yes or No","type":"yes-no","label":"The Company's outside auditor changed?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Any acquisition(s) or merger(s) taken place?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach separate sheet with details","type":"attachment","label":"If 'YES' has been answered to any of the above, please give full details under separate attachment.","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are any acquisitions/mergers/takeovers planned within the next year?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Company aware of any proposals of its being acquired by another company?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Does the Company intend to make any new public offering within the next year?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the Company or any of its subsidiaries listed on any stock exchanges or any organised markets?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach separate sheet with details","type":"attachment","label":"If 'YES' has been answered to any of the above, please give full details under separate attachment.","options":[],"required":false,"pdf_field":""}],"filled_by":"company"},{"title":"Shareholders Owning 5% or More","fields":[{"help":"Provide Name and Percentage (%) ownership","type":"table","label":"Please list name(s) of shareholder(s) owning directly or indirectly 5% or more of the Company's shares.","options":[],"required":true,"pdf_field":""}],"filled_by":"company"},{"title":"Subsidiaries Created, Dissolved or Sold in Last 12 Months","fields":[{"help":"Provide Name, Business or Type of Operations, Percentage of Ownership, Date Acquired, Sold or Dissolved","type":"table","label":"Please complete a list of subsidiaries created, dissolved or sold in the last twelve (12) months:","options":[],"required":false,"pdf_field":""}],"filled_by":"company"},{"title":"Credit or Bond Rating","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Does the Company have a credit or bond rating?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide rating organisation name, year and rating result","type":"text","label":"If 'YES', please state name of rating organisation, last year of rating and result","options":[],"required":false,"pdf_field":""}],"filled_by":"company"},{"title":"Year 2000 Exposure and Insurance History","fields":[{"help":"Describe past and planned steps regarding Y2K exposure","type":"text","label":"What has your Company done in the past in order to cope with the Year 2000 exposure and which further steps are planned in your head-office as well as in your subsidiaries (e.g. with reference to your most important suppliers and customers)?","options":[],"required":false,"pdf_field":""},{"help":"Specify required limits of liability","type":"text","label":"Limits of Liability required?","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have any claims ever been made against any past or present Director or Officer of the Company or any of its subsidiaries in respect of Directors and Officers liability?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Is the applicant or any of the Directors or Officers aware of any circumstances or incidents that might give rise to a claim under the proposed insurance?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has notice of any fact, circumstances or situation or wrongful act been given under any prior Directors and Officers Liability Insurance?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Has any insurer ever declined, cancelled, refused to renew or required to reduce limits of any Directors and Officers liability or similar insurance policy?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Attach separate sheet with details","type":"attachment","label":"If 'YES' has been answered to any of the above, please give full details under separate attachment.","options":[],"required":false,"pdf_field":""},{"help":"Specify deductible amount","type":"amount","label":"Deductible Amount","options":[],"required":true,"pdf_field":""}],"filled_by":"company"},{"title":"External Directorships","fields":[{"help":"Provide Name of Outside Company, Nature of Business, Country of Incorporation, % Ownership, Individual Directors Name, Type of Entity","type":"table","label":"Please provide details of companies of which external directorships are held at the request of the Company and for which Directors and Officers Liability Insurance is required, if acceptable to the Underwriter","options":[],"required":false,"pdf_field":""}],"filled_by":"company"},{"title":"North America Jurisdiction Details (If Applicable)","fields":[{"help":"Provide total gross assets value","type":"amount","label":"Please give the total gross assets of the group in North America","options":[],"required":false,"pdf_field":""},{"help":"List subsidiaries in North America","type":"text","label":"Please list those subsidiaries in North America","options":[],"required":false,"pdf_field":""},{"help":"Provide minority stock owners","type":"text","label":"For each company, who owns the minority stock?","options":[],"required":false,"pdf_field":""},{"help":"Provide date of last offer/tender/issue","type":"date","label":"If 'YES', on what date was the last offer / tender / issue made?","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Was the offer subject to The United States Securities Act of 1933 and/or The Security Exchange Act of 1934, and/or any amendments thereto?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach separate sheet with details","type":"attachment","label":"If 'YES' has been answered to any of the above, please give full details under separate attachment.","options":[],"required":false,"pdf_field":""}],"filled_by":"company"},{"title":"Declarations and Signatures","fields":[{"help":"Sign here","type":"signature","label":"Signature of Authorised Officer","options":[],"required":true,"pdf_field":""},{"help":"State capacity or designation","type":"text","label":"Capacity","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Company name","type":"text","label":"Company","options":[],"required":true,"pdf_field":""},{"help":"Politically Exposed Persons status","type":"choice","label":"Are you or any of the proposal applicants a PEP or a close relative of PEP?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Signature of proposer","type":"signature","label":"Declaration: The content of this form and its particulars have been explained by me in vernacular to the proposer who has understood and confirmed the same.","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Name of witness","type":"text","label":"Name of Witness","options":[],"required":true,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness","options":[],"required":true,"pdf_field":""},{"help":"Date of witness signature","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of witness signature","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Disability Declaration: Any Physical deformity or handicap","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details and attach Disability Certificate issued by Medical Board","type":"text","label":"If Yes. Please provide details","options":[],"required":false,"pdf_field":""},{"help":"Signature of authorised 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":""},{"help":"Tick to confirm","type":"checkbox","label":"Claim Docs: 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":"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 code and signature","type":"text","label":"Agent / IMD (SP/DP/BQP) signature and their code","options":[],"required":true,"pdf_field":""},{"help":"Agent or IMO name","type":"text","label":"Agent/IMO Name","options":[],"required":true,"pdf_field":""},{"help":"Agent or IMO code","type":"text","label":"Agent/IMO Code","options":[],"required":true,"pdf_field":""},{"help":"Name of SP/BQP/DP/PoS","type":"text","label":"SP/BQP/DP/PoS Name","options":[],"required":true,"pdf_field":""},{"help":"Code of SP/BQP/DP/PoS","type":"text","label":"SP/BQP/DP/PoS CoR No.","options":[],"required":true,"pdf_field":""},{"help":"Signature of SP/BQP/DP/PoS","type":"signature","label":"SP/BQP/DP/PoS Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"authorised officer / proposer / agent"}],"deadlines":[],"applies_to":"Directors & Officers Liability and Company Reimbursement Policy (Claims Made Policy)","attachments":["If there is insufficient space in this proposal for you to provide relevant information, attach a separate sheet","Full details of any changes, acquisitions, mergers, or incidents if answered YES to related questions","Two latest available audited Annual Reports and Accounts for the Company","Latest available Interim Statement (if applicable)","Any offer and/or filing documents/listing particulars published in the last twenty four months","Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability (if applicable)"],"declarations":["This proposal and any other information supplied shall constitute the complete proposal and basis of the contract if policy is issued.","Statements and particulars in this proposal are true and no material facts have been misstated or suppressed.","Undertake to inform the Underwriter of any material alteration before completion of the Contract of Insurance.","Premium has been paid out of legally acquired sources of income and subsequent premiums will be paid similarly.","Consent to verify identity/address proof through specified government portals for KYC purposes.","Consent to share personal information with group companies or others for insurance or related services.","No person shall offer or accept rebates except as allowed by insurer's published prospectus or tables.","Agent/intermediary declares that contents of the proposal form have been explained to the proposer in vernacular if required.","If untrue statements or non-disclosure of material facts occur, the policy may be varied or treated as null and void."],"dropped_labels":11},"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/2491-bajaj-general-protect-platinum-ii-directors-and-officers-liability-and-company-r"}