{"id":2497,"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-pf.pdf","sha256":"5aebb78b461e64e6bab9af7c6205a24a80e2c8a3f95859960505ff24714cc5b6","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by firms or professionals to apply for Professional Indemnity Insurance coverage from Bajaj General Insurance Limited. The proposer (firm, partners, directors) fills it out.","notes":["Answer all questions fully and accurately to avoid claim rejection or policy avoidance.","Attach separate sheets if space is insufficient.","Use original documents for claims processing when requested.","Keep policy contact and bank details updated for faster service.","The form includes a declaration about politically exposed persons (PEPs).","The form must be signed by proposer, witness, and agent/intermediary.","Disability declaration requires a government-issued certificate if applicable."],"title":"Professional Indemnity Insurance Proposal Form","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Firm and Contact Details","fields":[{"help":"Enter the full legal name of the firm applying for insurance.","type":"text","label":"Name of Firm","options":[],"required":true,"pdf_field":""},{"help":"Enter the mailing address for correspondence.","type":"text","label":"Correspondence address of office","options":[],"required":true,"pdf_field":""},{"help":"List addresses of any additional offices.","type":"text","label":"Address of all other offices","options":[],"required":false,"pdf_field":""},{"help":"Indicate if you are an existing customer of the insurer.","type":"yes-no","label":"Existing Customer","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide your electronic insurance account details if applicable.","type":"text","label":"Electronic-Insurance Account","options":[],"required":false,"pdf_field":""},{"help":"Provide bank account details for premium payments.","type":"text","label":"Bank Account detail","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Nature of Business and Staff Details","fields":[{"help":"Describe your professional 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":true,"pdf_field":""},{"help":"Provide the date or year the firm was established.","type":"date","label":"When was Firm established","options":[],"required":true,"pdf_field":""},{"help":"List each partner/director/sole practitioner with their qualifications, date qualified, and years with the firm.","type":"table","label":"Give details of partners/directors/sole practitioner: Name, Qualifications, Date Qualified, Number of years in this capacity with Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter the number of permanent non-technical staff.","type":"number","label":"State number of permanent staff: Non-Technical Staff","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Constitution Details","fields":[{"help":"Tick if your firm is a partnership.","type":"checkbox","label":"Partnership Firm","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick if your firm is a limited liability or LLP.","type":"checkbox","label":"Limited Liability/Partnership Firm","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick if NGO/NPO and provide DARPAN registration details if applicable.","type":"checkbox","label":"NGO/NPO - Provide DARPAN Portal Registration, if applicable","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick if your firm is a company.","type":"checkbox","label":"Company","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick if your firm is a trust.","type":"checkbox","label":"Trust","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick if your firm is a society.","type":"checkbox","label":"Society","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick if your firm is a Section 8 company.","type":"checkbox","label":"Section 8 Company","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick if your firm is a proprietorship.","type":"checkbox","label":"Proprietorship Firm","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify any other constitution type if applicable.","type":"text","label":"Others (Please specify)","options":[],"required":false,"pdf_field":""},{"help":"Provide any additional details about the constitution.","type":"text","label":"Constitution Details","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":"Related Companies and Financial Information","fields":[{"help":"Indicate if you or partners/directors work for related companies.","type":"yes-no","label":"Does the proposer or any partner / director act on behalf of or undertake for work for any company or business which forms part of the same group of companies or businesses as the Proposer (e.g. subsidiary, associate, parent)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate if you or partners/directors have financial interest and influence in other companies.","type":"yes-no","label":"Does the proposer or any partner / director act on behalf of or undertake for work for any company or business 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","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if answered Yes above.","type":"text","label":"If 'Yes' in either case, please give details","options":[],"required":false,"pdf_field":""},{"help":"Provide start and end dates of your financial year.","type":"text","label":"State the dates of the financial year","options":[],"required":true,"pdf_field":""},{"help":"Provide gross fees or turnover for: (i) In territory where domiciled, (ii) In USA/Canada or elsewhere for clients with USA/Canada address, (iii) Elsewhere, and total.","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.","options":[],"required":true,"pdf_field":""},{"help":"Indicate if you have representation in USA or Canada.","type":"yes-no","label":"Is the Proposer represented in any way in the USA or Canada?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe the nature of representation in USA/Canada.","type":"text","label":"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":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Existing Insurance and Coverage Requirements","fields":[{"help":"Indicate if you currently have professional indemnity insurance.","type":"yes-no","label":"Does the Proposer currently hold any Professional Indemnity Insurance?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide renewal date of current policy.","type":"date","label":"If 'Yes' state Renewal Date","options":[],"required":false,"pdf_field":""},{"help":"Indicate if you want coverage for previous business of partners.","type":"yes-no","label":"Is cover required for Partners' Previous Business?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide name of partner for previous business coverage.","type":"text","label":"If 'Yes' state Name of Partner","options":[],"required":false,"pdf_field":""},{"help":"Indicate if you want loss of documents coverage.","type":"yes-no","label":"Please indicate if the following covers are required: Loss of Documents","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if documents are kept in fireproof cabinets.","type":"yes-no","label":"If 'Yes', does the Proposer keep documents in fire proof cabinets?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if you want libel and slander coverage.","type":"yes-no","label":"Please indicate if the following covers are required: Libel and Slander","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if you want coverage for dishonesty of employees.","type":"yes-no","label":"Please indicate if the following covers are required: Dishonesty of Employees","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance History and Claims","fields":[{"help":"Indicate if any insurer has declined, refused renewal, or terminated your insurance.","type":"yes-no","label":"Has any insurer in respect of the risks to which this proposal relates ever declined a proposal, refused renewal or terminated an insurance?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if answered Yes above.","type":"text","label":"If 'Yes' in either case, please give details","options":[],"required":false,"pdf_field":""},{"help":"Indicate if any claims have been made for professional negligence or errors.","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":true,"pdf_field":""},{"help":"Indicate if any other losses or expenses have been incurred that might be covered.","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":true,"pdf_field":""},{"help":"Provide detailed information about each claim or loss.","type":"text","label":"If 'Yes' in either case, please give details separately of the circumstances of each incident including any amounts paid and the estimated potential cost of the incident.","options":[],"required":false,"pdf_field":""},{"help":"Provide details if answered Yes above.","type":"text","label":"If 'Yes', please give details separately","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Indemnity and Payment Details","fields":[{"help":"Specify the indemnity amount you require and any alternatives for quotes.","type":"amount","label":"What is the amount of Indemnity required? Please state any alternative amounts for which a quotation is required","options":[],"required":true,"pdf_field":""},{"help":"Specify the deductible or contribution amount per claim 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":true,"pdf_field":""},{"help":"Select the mode of payment for the premium.","type":"choice","label":"Mode of Payment : Cheque / DD / Cash / Other","options":["Cheque","DD","Cash","Other"],"required":true,"pdf_field":""},{"help":"If payment is by cheque, specify who gave the cheque.","type":"choice","label":"Cheque - Given by : Spouse / Father / Mother / Son/Daughter / Employer / Employee / Financier","options":["Spouse","Father","Mother","Son/Daughter","Employer / Employee","Financier"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Sign here to confirm the proposal.","type":"signature","label":"Signature of Partner / Director","options":[],"required":true,"pdf_field":""},{"help":"Affix company stamp if available.","type":"text","label":"Company Stamp","options":[],"required":false,"pdf_field":""},{"help":"Date of signing the proposal.","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Agent or intermediary signs to confirm explanation to 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":"Proposer signs here.","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Date of proposer signature.","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 to proposer signature.","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":"Declare any physical disability.","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 Government Medical Board.","type":"text","label":"If Yes, Please provide details","options":[],"required":false,"pdf_field":""},{"help":"If proposer is disabled, name of authorised representative.","type":"text","label":"Name of Authorised Representative","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 authorised representative signature.","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Place of authorised representative signature.","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"Signature of sales person or broker.","type":"signature","label":"SP/BQP/DP/PoS Signature","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer and agent"}],"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 proposal form statements are true and complete and form the basis of the insurance contract.","Signing the form does not bind the proposer to complete the insurance.","No rebates of commission or premium are allowed as per Section 41 of the Insurance Act 1938.","Consent to verify identity/address proof through official portals for KYC.","Premiums are paid from legally acquired sources.","Consent to share personal information with group companies for insurance and related services.","Agent/intermediary has explained the form contents in vernacular and confirmed proposer understanding.","Non-disclosure or untrue statements may lead to policy variation or nullification.","Proposer confirms all relevant documents have been provided and will provide claim documents on demand."],"dropped_labels":22},"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/2497-professional-indemnity-insurance-proposal-form"}