{"id":2504,"title":"Environment Protect- Premises (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-Premises/Environment-Protect-Premises-pf.pdf","sha256":"74e59026606b51cc70a7036b897f737c0d5f8b212a8f8a5cf9f2238383c55125","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for insurance coverage under the Environment Protect Premises policy. It is filled by the proposer (applicant) seeking insurance.","notes":["If there is insufficient space to provide information, attach a separate sheet.","All underground storage tanks are excluded under the policy unless specifically endorsed.","No coverage for offsite pipelines unless specifically endorsed.","Use original documents for attachments where applicable.","This proposal form is also deemed to be the proposal form for renewal of cover.","Insurance Act 1938 Section 41 prohibits rebates as inducements for insurance."],"title":"Environment Protect- Premises (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 website URL if available","type":"text","label":"Company Website:","options":[],"required":false,"pdf_field":""},{"help":"Attach relevant environmental reports if Yes","type":"choice","label":"Are there any environmental reports and documents available? ( Yes/No) If Yes Please provide all documents","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"List each location with Occupancy Type and Ownership Type (Owned/Leased/Other)","type":"table","label":"Locations to be covered under this policy: Note: Please indicate -: each occupancy (eg factory, warehouse, office etc) and ownership (eg owned, leased, others)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E mail ID","options":[],"required":null,"pdf_field":""},{"help":"Select the constitution type of the proposer","type":"choice","label":"Constitution Details","options":["Partnership Firm","Limited Liability/Partnership Firm","NGO/NPO","Company","Trust","Society","Section 8 Company","Proprietorship Firm","Others (Please specify)"],"required":null,"pdf_field":""},{"help":"Provide DARPAN Portal Registration if applicable","type":"text","label":"DARPAN DETAILS","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Risk Specific Information","fields":[{"help":"Describe the nature of the business","type":"text","label":"Applicant Business","options":[],"required":null,"pdf_field":""},{"help":"Provide estimated gross revenue for each period","type":"amount","label":"Total estimated gross revenue: Last 12 months / Current 12 months / Next 12 months","options":[],"required":null,"pdf_field":""},{"help":"If Yes, describe the planned changes","type":"choice","label":"Are there planned, change in use of operations during the policy term? If yes, please include a description of the future use","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe previous uses of the property","type":"text","label":"Past property uses","options":[],"required":null,"pdf_field":""},{"help":"Describe the land use around the property","type":"text","label":"Surrounding land use","options":[],"required":null,"pdf_field":""},{"help":"If Yes, provide details and estimated revenues","type":"choice","label":"Do you conduct any contracting activities outside of your property? If yes, please state estimated annual revenues and details of these activities.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, complete Appendix A for details","type":"choice","label":"Are there any above ground storage tanks on the property? If yes, please complete APPENDIX A.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, complete Appendix A for details","type":"choice","label":"Are there current underground storage tanks on the property? If yes, please complete APPENDIX A.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, attach evidence of proper closure","type":"choice","label":"Were there any underground storage tanks on the property, which are closed? If yes, please include evidence of proper closure.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, complete Appendix B for details","type":"choice","label":"Are there any aboveground pipelines on the property? If yes, please complete APPENDIX B.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, complete Appendix B and attach inspection/integrity test reports","type":"choice","label":"Are there underground pipelines on the property? If yes, please complete APPENDIX B. Please provide most recent inspection report and/or integrity test report.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If Yes, attach water intrusion/management plan and loss history","type":"choice","label":"Are you requesting coverage for microbial matter (mold)? If yes, please provide a copy of water intrusion plan / management plan and five (5) years general liability loss history.","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Transportation","fields":[{"help":"Provide number of owned and third party vehicles","type":"number","label":"Total number of vehicles: Owned Vehicles / Third Party Transporters","options":[],"required":null,"pdf_field":""},{"help":"Provide number of vehicles by type hauling hazardous materials","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":"text","label":"Maximum radius of transportation","options":[],"required":null,"pdf_field":""},{"help":"If Yes, provide explanation","type":"choice","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":""}],"filled_by":"proposer"},{"title":"Loss History","fields":[{"help":"","type":"choice","label":"In the last five (5) years, has the applicant had any reportable releases or spills of hazardous substances, hazardous wastes, or any other pollutants?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"In the last five (5) years, has the applicant been prosecuted, cited or named, or is currently being prosecuted, cited or named, for any violation of any standard or law relating to the release or threatened release of a pollutant?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Describe claims related to environmental releases","type":"text","label":"Please describe any claims made against the applicant during the last five (5) years for clean-up or response action, toxic tort or bodily injury or property damage, resulting from the release of hazardous materials or waste, or any other pollutant into the environment.","options":[],"required":null,"pdf_field":""},{"help":"Answer based on knowledge of potential claims","type":"choice","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 arising from the release of pollutants into the environment?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Existing and Required Coverage","fields":[{"help":"Provide details of existing pollution insurance 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":"Answer each question and provide details if Yes","type":"choice","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? (If answer to a, b, c above is “Yes” please provide details)","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 the proposal","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing the proposal","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"To be signed by company intermediary if applicable","type":"signature","label":"Signature of Intermediary/Officer of the Company","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the Intermediary/Officer of the Company","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Code Number/Employee Number","options":[],"required":false,"pdf_field":""},{"help":"PEP means Politically Exposed Person as defined","type":"choice","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":""}],"filled_by":"proposer"}],"deadlines":[],"applies_to":"Environment Protect Premises insurance policy","attachments":["Environmental reports and documents if available","Evidence of proper closure of underground storage tanks if applicable","Most recent inspection report and/or integrity test report for underground pipelines if applicable","Water intrusion plan / management plan and five (5) years general liability loss history if requesting coverage for microbial matter (mold)"],"declarations":["The information provided in this proposal form is complete, true and accurate to the best of the proposer's knowledge.","Incorrect, untrue, suppressed or misleading information may result in rejection of claim or cancellation of policy.","The proposer agrees to inform the company immediately of any changes after submission of this proposal.","The insurance contract is effective only upon company acceptance and receipt of full premium.","The proposer authorizes display of standard terms and conditions on the company website if agreed.","The proposer agrees that the policy terms have been explained in vernacular language if agreed.","The proposer consents to KYC verification through CERSAI or NSDL portals.","The proposer declares premiums are paid from legally acquired sources.","The proposer consents or does not consent to sharing personal information with company group and others."],"dropped_labels":8},"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/2504-environment-protect-premises-proposal-form"}