{"id":2494,"title":"Bajaj General Protect Public Offering of Securities Insurance PROPOSAL FORM (Claims Made Policy)","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/commercial-general/POSI-pf.pdf","sha256":"001ce4deed35402cf38daa7576faab5d1e44d6a55a7cb7427e6b4e11c14efad2","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for insurance coverage related to public offerings of securities, to be filled by the company seeking insurance.","notes":["If insufficient space, attach separate sheets with relevant information","Use Disability Certificate issued by Government Medical Board for disability details","Keep policy contact and bank details updated via app, WhatsApp, call center, email, website, agent or branch","Original bills and documents may be required for claims processing on demand","Form must be signed by authorized officer and witnessed","Agent must provide license number and sign the form"],"title":"Bajaj General Protect Public Offering of Securities Insurance PROPOSAL FORM (Claims Made Policy)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Company Details","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":"Provide bank account details for claim payments","type":"text","label":"Bank Details Name as pr Bank","options":[],"required":true,"pdf_field":""},{"help":"","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 payment through 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 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 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":""},{"help":"Provide date of company incorporation","type":"date","label":"Date of Incorporation","options":[],"required":true,"pdf_field":""},{"help":"Provide country where company is registered","type":"text","label":"Country of Registration","options":[],"required":true,"pdf_field":""},{"help":"Provide postal pin code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Provide duration in years or months","type":"text","label":"How long has the company continuously been in business?","options":[],"required":true,"pdf_field":""},{"help":"Provide total number of company locations","type":"number","label":"Total Number of Locations","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer (company)"},{"title":"Constitution Details","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Partnership Firm","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Limited Liability/Partnership Firm","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No and provide DARPAN registration if applicable","type":"yes-no","label":"NGO/NPO - Provide DARPAN Portal Registration, if applicable","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Company","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Trust","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Society","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Section 8 Company","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Proprietorship Firm","options":[],"required":false,"pdf_field":""},{"help":"Specify other constitution if applicable","type":"text","label":"Others (Please specify)","options":[],"required":false,"pdf_field":""},{"help":"Provide DARPAN portal registration details if applicable","type":"text","label":"DARPAN DETAILS","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Public Offering and Securities Details","fields":[{"help":"Select Yes or No","type":"choice","label":"Are subsidiaries publicly traded or the subject of a shelf registration?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide equity details","type":"text","label":"Equity","options":[],"required":false,"pdf_field":""},{"help":"Provide debt details","type":"text","label":"Debt","options":[],"required":false,"pdf_field":""},{"help":"Provide mixed securities details","type":"text","label":"Mixed","options":[],"required":false,"pdf_field":""},{"help":"Provide total voting shares","type":"number","label":"Total number of voting shares outstanding","options":[],"required":false,"pdf_field":""},{"help":"Provide total voting shareholders","type":"number","label":"Total number of voting shareholders","options":[],"required":false,"pdf_field":""},{"help":"Provide number of shares owned by directors and officers","type":"number","label":"Total number of voting shares owned by the Company's directors and officers, both direct and beneficial","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Does any shareholder own 15% or more of the voting shares directly or beneficially?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide shareholder names and percentages or state 'none'","type":"text","label":"If yes, please give the shareholders name and percentage of holdings","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Are there any other securities convertible to voting shares?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide subsidiary details in table format","type":"table","label":"Please list all direct and indirect subsidiary companies (Name, Business or Type of Operations, Percentage of Ownerships, Date Acquired or Created, Country of Incorporation)","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Does the Proposer or any director or officer have Directors and Officers Liability Insurance cover currently in force?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide insurer name","type":"text","label":"If yes, please state: a) Insurer","options":[],"required":false,"pdf_field":""},{"help":"Provide indemnity limit","type":"text","label":"b) Indemnity Limit","options":[],"required":false,"pdf_field":""},{"help":"Provide expiry date","type":"date","label":"c) Expiry Date","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Has the Company ever had any Insurer decline a proposal or cancel or refuse to renew a Directors and Officers Liability Insurance?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details on separate sheet","type":"text","label":"If yes, please give details","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Cover Extension for Additional Insureds","fields":[{"help":"Tick all that apply","type":"checkbox","label":"Is the Proposer requesting cover for any of the following for Securities Claims in connection with the public offering?","options":["Controlling Shareholders","Selling Shareholders","Underwriters","Solicitors for the Company","Solicitors for the Underwriters","Accountants","Experts"],"required":false,"pdf_field":""},{"help":"Attach separate sheet with details","type":"text","label":"If yes, and such individuals or entities are not referred to in the Particulars or Registration Statement, please provide full details of each individual on a separate sheet","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Initial Public Offering Particulars","fields":[{"help":"Provide filing date and registration statement number; continue on separate sheet if necessary","type":"table","label":"Please give the filing date of the particulars/ registration statement number for all Initial Public Offerings, including any SEC Registration Statements","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Merger, Acquisition or Consolidation Plans","fields":[{"help":"Select Yes or No","type":"choice","label":"Are any plans for merger, acquisition or consolidation of or by the Proposer or any of its subsidiaries being considered?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"If yes, have they been approved by the board of directors?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"If so, have they been submitted to the shareholders for approval?","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Future Securities Registration","fields":[{"help":"Select Yes or No","type":"choice","label":"Does the Proposer or any of its subsidiaries anticipate any registration of securities under the Securities Act of 1933 or any other offering of securities other than the Initial Public Offering described above, within the next year?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Claims Information","fields":[{"help":"Select YES or NO","type":"choice","label":"Has there been or is there now pending any claim(s) against a director, officer or employee proposed for insurance in his or her capacity as a director, officer or employee of the Proposer or any of its subsidiaries?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Attach separate sheet with details","type":"text","label":"If yes, please give full details on a separate sheet","options":[],"required":false,"pdf_field":""},{"help":"Select YES or NO","type":"choice","label":"Has there been or is there now pending any claim(s) against the Proposer or any of its subsidiaries with regard to the securities of the Proposer or any of its subsidiaries?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Attach separate sheet with details","type":"text","label":"If yes, please give full details on a separate sheet","options":[],"required":false,"pdf_field":""},{"help":"Select YES or NO","type":"choice","label":"Does the Proposer or any of its subsidiaries have knowledge or information of any act, error or omission which might give rise to a securities claim under the proposed policy?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Attach separate sheet or write 'none'","type":"text","label":"If yes, please attach complete details on a separate sheet or state 'none'","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Indemnity Limit","fields":[{"help":"Select indemnity amount or specify other","type":"choice","label":"Please indicate amount of indemnity required","options":["US$5,000,000","US$10,000,000","US$15,000,000","Other, please state"],"required":true,"pdf_field":""},{"help":"Specify other indemnity amount if selected","type":"amount","label":"Other, please state","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Attachments to Enclose","fields":[{"help":"Attach all relevant offer documents","type":"attachment","label":"All offer documents or listing particulars (including any registration statements with the SEC) filed within the last twelve months, including any amendments thereto","options":[],"required":true,"pdf_field":""},{"help":"Attach final particulars document","type":"attachment","label":"A copy of the final particulars in connection with the Initial Public Offering","options":[],"required":true,"pdf_field":""},{"help":"Attach underwriting agreement","type":"attachment","label":"A copy of the underwriting agreement, which sets forth the indemnification of the Proposer in connection with the Initial Public Offering","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration and Signature","fields":[{"help":"Sign here","type":"signature","label":"Signature of Authorized 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":"Name of company","type":"text","label":"Company","options":[],"required":true,"pdf_field":""}],"filled_by":"authorized officer of proposer"},{"title":"Declarations and Consents","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":true,"pdf_field":""},{"help":"Keep contact and bank details updated for faster service","type":"yes-no","label":"It is mandatory to keep your policy with updated contact and bank account details","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Proposer and Witness Declaration","fields":[{"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":""}],"filled_by":"proposer and witness"},{"title":"Disability Declaration","fields":[{"help":"Select Yes or No","type":"choice","label":"Any Physical deformity or handicap","options":["Yes","No"],"required":true,"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 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":""}],"filled_by":"proposer or authorized representative"},{"title":"Claim Documents Confirmation","fields":[{"help":"Tick to confirm all documents 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","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 license number","type":"text","label":"IRDAI COR No./ License No.(Advisor/Corporate Agent/Broker/Relationship Officer)","options":[],"required":true,"pdf_field":""},{"help":"Agent signature","type":"signature","label":"Signature of Agent","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":"Provide agent code and signature","type":"text","label":"Agent/IMD (SP/DP/BQP) signature and their code","options":[],"required":false,"pdf_field":""},{"help":"Name of SP/BQP/DP/PoS","type":"text","label":"SP/BQP/DP/PoS Name","options":[],"required":false,"pdf_field":""},{"help":"Code of SP/BQP/DP/PoS","type":"text","label":"SP/BQP/DP/PoS CoR No.","options":[],"required":false,"pdf_field":""},{"help":"Signature of SP/BQP/DP/PoS","type":"signature","label":"SP/BQP/DP/PoS Signature","options":[],"required":false,"pdf_field":""}],"filled_by":"agent or intermediary"}],"deadlines":[],"applies_to":"Public Offering of Securities Insurance Policy","attachments":["All offer documents or listing particulars (including any registration statements with the SEC) filed within the last twelve months, including any amendments thereto","A copy of the final particulars in connection with the Initial Public Offering","A copy of the underwriting agreement, which sets forth the indemnification of the Proposer in connection with the Initial Public Offering"],"declarations":["The statements in this proposal are true and must be updated if changed before policy effective date","Signing this application does not bind either party but forms basis of contract if policy issued","No person shall offer or accept rebates on commission or premium except as allowed by insurer's published prospectuses","Consent to verify identity/address proof through official registries","Declaration that premium is paid from legally acquired income","Consent to share personal data with group companies for services","Policy must have updated contact and bank details for faster service","Proposer and witness confirm understanding and explanation of form contents","Agent/intermediary confirms explanation of form contents to proposer"],"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/2494-bajaj-general-protect-public-offering-of-securities-insurance-proposal-form-clai"}