{"id":2503,"title":"Environment Protect- Project (Proposal Form)","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/Environment-Protect-Project/Environment-Protect-Project-pf.pdf","sha256":"c43a4d74043290fafd37e5ca28f56345636713ee9e5806e73c64d92079875f76","pages":8,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for insurance coverage related to environmental protection projects. It is filled by the proposer (applicant) seeking insurance.","notes":["Use additional sheets if space is insufficient","This form is the basis of the insurance contract","The Insurance Act 1938 Section 41 prohibits rebates and inducements","Intermediary/Officer certification is required only if the proposer did not fill the form themselves"],"title":"Environment Protect- Project (Proposal Form)","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"","type":"text","label":"Name of the Proposer ( in full )","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"PAN/TAN Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address for Communication","options":[],"required":null,"pdf_field":""},{"help":"Include country and area code if applicable","type":"phone","label":"Telephone Number:","options":[],"required":null,"pdf_field":""},{"help":"Provide full URL if available","type":"text","label":"Company Website:","options":[],"required":false,"pdf_field":""},{"help":"Describe business activities and year established","type":"text","label":"Nature and type of Business (detail description) with establishment year:","options":[],"required":null,"pdf_field":""},{"help":"Select the applicable proposer type","type":"choice","label":"Proposer Type: Corporation/ Joint Venture/ Partnership Firm","options":["Corporation","Joint Venture","Partnership Firm"],"required":null,"pdf_field":""},{"help":"Provide number of personnel in each category","type":"number","label":"Please indicate number of applicant‘s personnels (breakdown by the category): Principals, Engineers and Architects, Geologists & Chemists, Certified Industrial Hygenists, Supervisors, Field Personnel, Others","options":[],"required":null,"pdf_field":""},{"help":"Provide registration details if applicable","type":"text","label":"DARPAN Portal Registration, if applicable","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Risk Specific Information","fields":[{"help":"Provide estimated revenue amount","type":"amount","label":"Total estimated gross revenue for the next 12-month period","options":[],"required":null,"pdf_field":""},{"help":"Provide previous year's revenue amount","type":"amount","label":"Gross revenue for the previous 12-month period","options":[],"required":null,"pdf_field":""},{"help":"Provide percentage revenue for each client type","type":"table","label":"Percentage Revenue Breakdown by Client (Industrial, Infrastructure, Manufacturing/Chemical Plants, Airports, Petrochemical/Refineries, Street/Roads, Pipelines, Bridges/Tunnels, Wastewater Sewage Plants, Harbors/Piers/Ports/Dams, Potable Water Systems, Offshore Marine, Power Plants, Landfills/Disposal Facilities, Residential/Habitational, Mass Transit/Railroad, Nuclear Facilities, Commercial, Municipal, Federal, State/Local, Healthcare, Airports/Terminals, Hospitality)","options":[],"required":null,"pdf_field":""},{"help":"Provide details for each of the 5 largest projects","type":"table","label":"List of 5 Largest Projects in the Last 3 Years: Project Name/Client, Actual Gross Revenue, Percentage Subcontracted, Start Date, Completion Date, Operations/Services Provided","options":[],"required":null,"pdf_field":""},{"help":"Indicate if such a procedure exists","type":"yes-no","label":"Do you have a written procedure for avoiding underground hazards? (Yes/No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if a health and safety plan exists","type":"yes-no","label":"Do you have a written health and safety plan? (Yes/No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if certificates are obtained","type":"yes-no","label":"Do you obtain certificates of insurance from your subcontractors? (Yes/No)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify minimum liability limits","type":"amount","label":"What are the minimum limits of liability you require of your subcontractors?","options":[],"required":null,"pdf_field":""},{"help":"Provide percentage for each agreement type","type":"number","label":"What percentage of jobs performed are the following agreements? Written contract, Letter agreement, Oral agreement","options":[],"required":null,"pdf_field":""},{"help":"Provide number of vehicles by type","type":"number","label":"Number of vehicles by types hauling hazardous materials: Light truck, Medium truck, Heavy/extra heavy truck","options":[],"required":null,"pdf_field":""},{"help":"Provide shipment frequency","type":"number","label":"Shipment per month / per year","options":[],"required":null,"pdf_field":""},{"help":"Provide maximum transportation radius","type":"number","label":"Maximum radius of transportation","options":[],"required":null,"pdf_field":""},{"help":"Indicate if pollution claims occurred and provide explanation if yes","type":"yes-no","label":"Have there been pollution claims/incidents from transportation in the past 5 years? If Yes, please explain","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if such SOP or QA plan exists","type":"yes-no","label":"Do you have a Standard Operating Procedure or Quality Assurance Plan designed to prevent microbial matter growth, or removal/remediation of microbial matter contamination? (Yes/No)","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Loss History","fields":[{"help":"Indicate if any known facts may lead to a claim","type":"yes-no","label":"At the time of signing this application, do you know of any facts or circumstances which may reasonably be expected to result in a claim? (Yes/No)","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Existing and Required Coverage","fields":[{"help":"Provide details of existing pollution coverage","type":"text","label":"Existing Pollution Coverage: Insuring Company, Limit of Liability, Deductible, Retroactive Date, Effective Date, Premium","options":[],"required":false,"pdf_field":""},{"help":"Provide requested coverage details","type":"text","label":"Requested Pollution Coverage: Limit of Liability, Deductible, Effective Date, Expiration Date","options":[],"required":false,"pdf_field":""},{"help":"Indicate yes or no for each question and provide details if yes","type":"yes-no","label":"Has any company/Insurer in respect of Insurance: a. Declined your Proposal? b. Cancelled or refused to renew your policy? c. Accepted your proposal on special terms and conditions? (Yes/No for each)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide any other relevant information","type":"text","label":"Additional relevant details (if any)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"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":"Sign the form","type":"signature","label":"Signature of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Tick if you agree","type":"checkbox","label":"I/We hereby authorize company that all Standard Terms & Conditions of policy can be displayed in the website of company that enables access by me/us if I/We want to know the terms and conditions of policy displayed on website. (Please tick in case same is agreed)","options":["Agree"],"required":false,"pdf_field":""},{"help":"Tick if you agree","type":"checkbox","label":"The salient features of the policy, terms and conditions of this proposal have been explained to me/us in vernacular language, and I/We agree to the same. (Please tick in case same is agreed)","options":["Agree"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Intermediary/Officer Certification (if applicable)","fields":[{"help":"Name of intermediary/officer certifying the form","type":"text","label":"Name of the Intermediary/Officer of the Company","options":[],"required":null,"pdf_field":""},{"help":"Code or employee number","type":"text","label":"Code Number/Employee Number","options":[],"required":null,"pdf_field":""},{"help":"Place and date of certification","type":"text","label":"Place and Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of intermediary/officer","type":"signature","label":"Signature of Intermediary/Officer of the Company","options":[],"required":null,"pdf_field":""}],"filled_by":"intermediary/officer"},{"title":"Additional Declarations","fields":[{"help":"Politically Exposed Persons details if applicable","type":"yes-no","label":"Are you or any of the proposal applicants a PEP* or a close relative of PEP*? If yes, please share the details","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 CERSAI records or National Securities Depository Limited Portal for the purpose of undertaking KYC verification.","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 information","type":"yes-no","label":"I/We hereby give voluntary consent to Bajaj General/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":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"environment protect project insurance proposals","attachments":["If there is insufficient space in this proposal for you to provide relevant information, please attach a separate sheet","Environmental reports and documents if available"],"declarations":["The information provided in this proposal form must be complete, true and accurate to the best of your knowledge","Failure to provide correct information may result in claim rejection and policy avoidance","You must immediately inform the company of any changes in the proposal or risk after submission","The insurance contract is effective only upon company acceptance and receipt of full premium","The proposal form is also deemed to be a renewal proposal form","Consent to display standard terms and conditions on company website if agreed","Salient features and terms have been explained in vernacular language if agreed","Declaration of legal source of premium payment","Consent for KYC verification","Consent to share personal information with group companies"],"dropped_labels":5},"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/2503-environment-protect-project-proposal-form"}