{"id":2500,"title":"PROPOSAL FORM FOR INSURANCE UNDER PUBLIC LIABILITY INSURANCE ACT 1991","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/public-liability-act-policy/Public-Liability-(Act)-pf2.pdf","sha256":"67016c7cdbfc4ea63e94b07090a7b7fd69b3bcc746810ba7620f066fba6ee923","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer (business owner or entity) to apply for public liability insurance under the Public Liability Insurance Act 1991.","notes":["Liability of the company commences only after receipt of premium and statutory contribution towards Environment Relief Fund","If space is insufficient, attach separate sheets for details","Insurance is the subject matter of solicitation","Use original documents for claims processing","Physical proposal form must be signed by proposer and witnessed","Disability declaration requires government-certified disability certificate","Keep policy details updated via app, WhatsApp, call center, email, website, agent or branch"],"title":"PROPOSAL FORM FOR INSURANCE UNDER PUBLIC LIABILITY INSURANCE ACT 1991","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"","type":"text","label":"Name of the Proposer ( in full )","options":[],"required":true,"pdf_field":""},{"help":"Enter your PAN or TAN number","type":"text","label":"PAN/TAN Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address for Communication","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter a valid email address","type":"email","label":"E mail ID","options":[],"required":false,"pdf_field":""},{"help":"Enter a valid mobile number","type":"phone","label":"Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Provide bank details as per bank records","type":"text","label":"Bank Details","options":[],"required":false,"pdf_field":""},{"help":"Name as per bank records","type":"text","label":"Name as pr Bank","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name Of Bank","options":[],"required":false,"pdf_field":""},{"help":"Enter your bank account number","type":"text","label":"Bank Account No.","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC code of your bank branch","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""},{"help":"Confirm acceptance to pay and receive claim amount in the above bank account","type":"yes-no","label":"* I accept to pay & receive claim amount (if any) in the above given Bank a/c","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide e-lA number if applicable","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":"IFSC code for e-lA account if applicable","type":"text","label":"IFSCCode","options":[],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Existin Customer: Are you an exisiting customer of Bajaj General?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide PID number if existing customer","type":"text","label":"If Yes. Please provide PID No:","options":[],"required":false,"pdf_field":""},{"help":"Provide policy number if existing customer","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Tick if 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":[],"required":false,"pdf_field":""},{"help":"Enter postal pin code","type":"text","label":"Pin Code","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Business and Risk Details","fields":[{"help":"Enter paid up capital as per note","type":"amount","label":"Paid up capital (See Note)","options":[],"required":true,"pdf_field":""},{"help":"List hazardous substances handled and their group","type":"text","label":"List of hazardous substances handled and Group (See Note)","options":[],"required":true,"pdf_field":""},{"help":"Provide details or state 'No such known and/or Reported claim so far'","type":"text","label":"Details of all accidents during past 3 years and compensation paid/claimed but not yet paid","options":[],"required":true,"pdf_field":""},{"help":"Provide estimated annual turnover for proposed and previous financial years","type":"amount","label":"Estimated annual turnover (See note)","options":[],"required":true,"pdf_field":""},{"help":"Enter turnover for proposed year","type":"amount","label":"Proposed Insurance Year: For the Financial year 2008-09","options":[],"required":true,"pdf_field":""},{"help":"Enter turnover for previous year","type":"amount","label":"Previous Year For the Financial year 2007-08","options":[],"required":true,"pdf_field":""},{"help":"Enter number of workmen employees","type":"number","label":"Number of (a) Workmen Employees","options":[],"required":true,"pdf_field":""},{"help":"Enter number of other employees","type":"number","label":"(b) Other employees","options":[],"required":true,"pdf_field":""},{"help":"Enter total number of employees","type":"number","label":"Total employees in number","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Constitution Details","fields":[{"help":"Select Yes or No","type":"yes-no","label":"Partnership Firm","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Limited Liability/Partnership Firm","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No and provide DARPAN details if applicable","type":"yes-no","label":"NGO/NPO - Provide DARPAN Portal Registration, if applicable","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Company","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Trust","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Society","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Section 8 Company","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Proprietorship Firm","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify other constitution if applicable","type":"text","label":"Others (Please specify)","options":[],"required":false,"pdf_field":""},{"help":"Provide details of 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":"Insurance Details and Declaration","fields":[{"help":"Enter limit of indemnity required","type":"amount","label":"Limit of Indemnity required in respect of Any one accident","options":[],"required":true,"pdf_field":""},{"help":"Enter start date and time (AM/PM)","type":"date","label":"Policy period required From","options":[],"required":true,"pdf_field":""},{"help":"Enter end date","type":"date","label":"To midnight of","options":[],"required":true,"pdf_field":""},{"help":"Consent to share information within group entities","type":"checkbox","label":"I/we hereby unconditionally allow the Company to share all my / our information being collected in this proposal form or through telephone / email / web-inputs means or other means, as updated from time to time within group entities.","options":[],"required":false,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign and provide company seal, name and designation","type":"signature","label":"Signature of the Proposer (Company Seal, Name, Designation)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Payment Details","fields":[{"help":"Select mode of payment","type":"choice","label":"Mode of Payment","options":["Cheque","DD","Cash","Other"],"required":true,"pdf_field":""},{"help":"Select who gave the cheque","type":"choice","label":"Cheque - Given by","options":["Spouse","Father","Mother","Son/Daughter","Employer / Employee","Financier"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consents","fields":[{"help":"Politically Exposed Persons declaration","type":"yes-no","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":"Confirm understanding of mandatory updates","type":"yes-no","label":"It is mandatory to keep your policy with updated contact (Mobile No., Email ID and PAN Card) and bank account details","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Physical Proposal Form Declaration","fields":[{"help":"Sign the form","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":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":"Declare if any physical deformity or handicap","type":"yes-no","label":"Any Physical deformity or handicap","options":["Yes","No"],"required":true,"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":"If proposer is disabled, authorised representative name","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":""}],"filled_by":"proposer or authorised representative"},{"title":"Claim Documents Confirmation","fields":[{"help":"Confirm all required documents have been 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":[],"required":true,"pdf_field":""},{"help":"Agree to submit additional documents if required","type":"checkbox","label":"Any document(s) as may be required, for claims processing, shall be submitted by me on demand by the company.","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent/Intermediary Declaration","fields":[{"help":"Agent signature","type":"signature","label":"Signature of Agent","options":[],"required":true,"pdf_field":""},{"help":"Date of signature","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signature","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Name of sales person or point of sale","type":"text","label":"SP/BQP/DP/PoS Name","options":[],"required":false,"pdf_field":""},{"help":"Code of sales person or point of sale","type":"text","label":"SP/BQP/DP/PoS CoR No.","options":[],"required":false,"pdf_field":""},{"help":"Signature of sales person or point of sale","type":"signature","label":"SP/BQP/DP/PoS Signature","options":[],"required":false,"pdf_field":""}],"filled_by":"agent"}],"deadlines":[],"applies_to":"Public Liability Insurance under the Public Liability Insurance Act 1991","attachments":["Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability","Separate sheets if space is insufficient for details"],"declarations":["All statutory provisions relating to the business proposed for insurance are complied with","The statements and particulars provided are true","No material fact has been omitted, suppressed, misrepresented or misstated","This declaration forms the basis of the contract between proposer and company","Consent to share information within group entities","Premium has been paid from legally acquired sources","Consent to share personal information with group companies","Policy must be kept updated with contact and bank details for faster service","Agent has explained the contents of the proposal form in vernacular to the proposer","Non-disclosure or untrue statements may lead to policy being void and forfeiture of premiums","Proposer confirms all relevant documents have been provided and will submit additional documents if required"],"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/2500-proposal-form-for-insurance-under-public-liability-insurance-act-1991"}