{"id":2496,"title":"Professional Indemnity Insurance Proposal Form","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/professional-indemnity-insurance-policy/Professional-Indemnity-pf2.pdf","sha256":"48ed1dd52a17eeba5289500d48aa3df6cb818ebe153736c9a9b75c2bc2ab50a6","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by firms or professionals to apply for Professional Indemnity Insurance coverage by providing details about their business, staff, financials, and insurance history.","notes":["Answer all questions fully and accurately to avoid claim rejection or policy avoidance.","Attach separate sheets if space is insufficient for any answers.","Use the Disability Certificate if declaring any physical deformity or handicap.","Keep policy contact and bank details updated via app, WhatsApp, call center, email, website, agent, or branch.","Agent/intermediary must explain the form contents in vernacular if required.","The form includes a disclaimer about confidentiality and virus protection for email communications."],"title":"Professional Indemnity Insurance Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Firm Details","fields":[{"help":"","type":"text","label":"Name of Firm","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Correspondence address of office","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address of all other offices","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Existing Customer","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Electronic-Insurance Account:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Bank Account detail","options":[],"required":null,"pdf_field":""},{"help":"Describe your profession/business activities and any planned changes","type":"text","label":"State nature of the profession / business including full details of activities undertaken and any intended change in these","options":[],"required":null,"pdf_field":""},{"help":"Provide the year or full date of establishment","type":"date","label":"When was Firm established","options":[],"required":null,"pdf_field":""},{"help":"List each partner/director/sole practitioner with their qualifications, date qualified, and years with proposer","type":"table","label":"Give details of partners/directors/sole practitioner\nName\nQualifications\nDate Qualified\nNumber of years in this capacity with Proposer","options":[],"required":null,"pdf_field":""},{"help":"Provide number of technical and non-technical permanent staff","type":"number","label":"State number of permanent staff\nTechnical Staff\nNon-Technical Staff","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Constitution Details","fields":[{"help":"","type":"yes-no","label":"Partnership Firm","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Limited Liability/Partnership Firm","options":[],"required":null,"pdf_field":""},{"help":"If yes, provide DARPAN registration details","type":"yes-no","label":"NGO/NPO - Provide DARPAN Portal Registration, if applicable","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Company","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Trust","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Society","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Proprietorship Firm","options":[],"required":null,"pdf_field":""},{"help":"Specify other constitution type if applicable","type":"text","label":"Others (Please specify)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Company and Group Details","fields":[{"help":"Answer Yes or No for each part and provide details if Yes","type":"yes-no","label":"Does the proposer or any partner / director act on behalf of or undertake for work for any company or business\n a) which forms part of the same group of companies or businesses as the Proposer (e.g. subsidiary, associate, parent) or\n b) in which the Proposer or any partner / director has a financial interest and is able to take or influence major policy decisions in such company or business\nIf 'Yes' in either case, please give details","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Financial Year and Fees","fields":[{"help":"Provide start and end dates of financial year","type":"text","label":"State the dates of the financial year","options":[],"required":null,"pdf_field":""},{"help":"Provide gross fees or turnover for each category and year","type":"table","label":"State the gross fees for the last and current financial year (including those paid to sub-contractors) payable by clients. If the business is newly established, state the estimated gross fees for the forthcoming year. For any non-fee earning business / practice, state total turnover.\ni) In territory where domiciled\nLast Financial Year\nCurrent Financial Year (Estimate)\nii) In the USA/Canada or elsewhere for clients whose address is in the USA/Canada\niii) Elsewhere\nTotal","options":[],"required":null,"pdf_field":""},{"help":"If Yes, describe the representation","type":"yes-no","label":"Is the Proposer represented in any way in the USA or Canada? If 'Yes', state how (e.g. by subsidiary company, local office, local representative or by any other person or concern holding a power of attorney on behalf of the Proposer)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide amounts for fees paid to sub-contractors and largest client fee","type":"table","label":"State\nLast Financial Year\na) gross fees paid to sub-contractors\nCurrent Financial Year (Estimate)\nb) largest fee earned from any client","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Existing Insurance and Cover Requirements","fields":[{"help":"If Yes, provide renewal date, indemnity limit, and retroactive date","type":"yes-no","label":"Does the Proposer currently hold any Professional Indemnity Insurance? If 'Yes' state\nRenewal Date\nLimit of Indemnity\nRetroactive Date","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide partner name, previous business title, and dates","type":"yes-no","label":"Is cover required for Partners' Previous Business? If 'Yes' state\nName of Partner\nTitle of Previous Business\nDates with Previous Business","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Answer Yes or No for each cover and for fire proof cabinet if Loss of Documents is Yes","type":"yes-no","label":"Please indicate if the following covers are required\ni) Loss of Documents\nIf 'Yes', does the Proposer keep documents in fire proof cabinets?\nii) Libel and Slander\niii) Dishonesty of Employees","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance History","fields":[{"help":"Answer Yes or No for each and provide details if Yes","type":"yes-no","label":"Has any insurer in respect of the risks to which this proposal relates ever\na) declined a proposal, refused renewal or terminated an insurance?\nb) required an increased premium or imposed special conditions?\nIf 'Yes' in either case, please give details","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Claims and Circumstances","fields":[{"help":"If Yes, provide details of each incident","type":"yes-no","label":"Has any claim been made against the Proposer or any partner, director, consultant or employee for neglect, error or omission in relation to professional duties?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, provide details of each incident","type":"yes-no","label":"Has the Proposer or any partner, director, consultant or employee incurred any other loss or expense which might be within the terms of the cover?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Indemnity and Contribution Amounts","fields":[{"help":"Specify indemnity amount and alternatives if any","type":"amount","label":"What is the amount of Indemnity required? Please state any alternative amounts for which a quotation is required","options":[],"required":null,"pdf_field":""},{"help":"Specify contribution amount and alternatives if any","type":"amount","label":"Please state the amount the Proposer wish to contribute towards each and every claim. Please state any alternative amounts for which a quotation is required","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select mode of payment","type":"choice","label":"Mode of Payment :\nCheque\nDD\nCash\nOther","options":["Cheque","DD","Cash","Other"],"required":null,"pdf_field":""},{"help":"Select who gave the cheque if applicable","type":"choice","label":"Cheque - Given by :\nSpouse\nFather\nMother\nSon/Daughter\nEmployer / Employee\nFinancier","options":["Spouse","Father","Mother","Son/Daughter","Employer / Employee","Financier"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Sign the form here","type":"signature","label":"Signature of Partner / Director","options":[],"required":true,"pdf_field":""},{"help":"Affix company stamp","type":"text","label":"Company Stamp","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"PEP and Consent Declarations","fields":[{"help":"Politically Exposed Persons status","type":"yes-no","label":"Are you or any of the proposal applicants a PEP or a close relative of PEP *?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Consent for KYC verification","type":"yes-no","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":null,"pdf_field":""},{"help":"Declaration of legal source of premium payment","type":"yes-no","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":null,"pdf_field":""},{"help":"Consent to share personal data","type":"yes-no","label":"I/We hereby give voluntary consent to BAGIC/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":""},{"help":"Acknowledge importance of updated contact and bank details","type":"checkbox","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":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration in Vernacular and Disability","fields":[{"help":"Sign here to confirm understanding","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Date of signature","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Name of witness to signature","type":"text","label":"Name of Witness","options":[],"required":null,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness","options":[],"required":null,"pdf_field":""},{"help":"If proposer is disabled, authorized representative name","type":"text","label":"Name of Authorised Representative","options":[],"required":null,"pdf_field":""},{"help":"Signature of authorized representative","type":"signature","label":"Signature of Authorised representative","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer or authorized representative"},{"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":null,"pdf_field":""},{"help":"Agent signature","type":"signature","label":"Signature of Agent","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Agent or IMD name","type":"text","label":"Agent/IMD Name","options":[],"required":null,"pdf_field":""},{"help":"Agent or IMD code","type":"text","label":"Agent/IMD Code","options":[],"required":null,"pdf_field":""},{"help":"Agent or IMD signature","type":"signature","label":"Agent/IMD Signature","options":[],"required":null,"pdf_field":""},{"help":"Code of sales person or broker","type":"text","label":"SP / BQP / DP / POS CoR No .","options":[],"required":null,"pdf_field":""},{"help":"Signature of sales person or broker","type":"signature","label":"SP / BQP / DP / PoS Signature","options":[],"required":null,"pdf_field":""},{"help":"Name of sales person or broker","type":"text","label":"SP / BQP / DP / PoS Name","options":[],"required":null,"pdf_field":""}],"filled_by":"agent or intermediary"}],"deadlines":[],"applies_to":"Professional Indemnity Insurance policies","attachments":["Separate sheet if insufficient space for information","Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability"],"declarations":["The statements made in this proposal are true and complete and form the basis of the insurance contract.","Signing this form does not bind the proposer to complete the insurance.","No person shall offer or accept rebates of commission or premium except as allowed by the insurer's published prospectus.","Failure to comply with rebate prohibition may result in a fine up to ten lakh rupees.","Consent is given to verify identity/address through specified government portals for KYC.","Premiums are declared to be paid from legally acquired sources.","Consent is given to share personal data with group companies for insurance and related services.","Policyholder must keep contact and bank details updated for faster service.","Agent declares having explained the form contents and consequences of untrue statements or non-disclosure.","The proposer or authorized representative confirms understanding of the form content in vernacular.","The proposer confirms having provided all relevant documents required for policy issuance."],"dropped_labels":6},"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/2496-professional-indemnity-insurance-proposal-form"}