{"id":2508,"title":"CLINICAL TRIAL LIABILITY INSURANCE POLICY (No Fault Compensation) PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/clinical-trial-liability-policy-legal-liability/Clinical-Trial-Legal-Liability-No-Fault-Compensation-pf.pdf","sha256":"8b864efec0deeced41ba0e8e25d6d0cc5f3852a658ba7cc090a31dda0e8b5dce","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by companies or bodies seeking insurance coverage for clinical trial liability under a no fault compensation policy. The proposer (company or body) fills it to provide details about their clinical trials and compliance.","notes":["Use typed or ink to complete the form.","Answer all questions fully.","Attach additional sheets if space is insufficient.","Disclose all material facts.","The form does not bind the proposer or insurer to a contract.","Section 41 of the Insurance Act 1938 prohibits rebates on insurance premiums."],"title":"CLINICAL TRIAL LIABILITY INSURANCE POLICY (No Fault Compensation) PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details and Declaration","fields":[{"help":"","type":"text","label":"Name of Company or Body to be insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Description of Business","options":[],"required":null,"pdf_field":""},{"help":"Format: date of establishment of the company or body","type":"date","label":"Date Established","options":[],"required":null,"pdf_field":""},{"help":"Specify which form is required and attach compensation agreement if applicable","type":"text","label":"Form required- Legal Liability or No fault Compensation, IF no fault compensation then please provide Compensation agreement/basis.","options":[],"required":null,"pdf_field":""},{"help":"Start date of the clinical trial period","type":"date","label":"Start date","options":[],"required":null,"pdf_field":""},{"help":"End date of the clinical trial period","type":"date","label":"End Date","options":[],"required":null,"pdf_field":""},{"help":"Answer yes or no for each sub-question below","type":"yes-no","label":"Are all trials conducted in full accordance with:","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"(a) Department of Health requirements with protocols approved by an independent Ethics Committee?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"(b) Royal College of Physicians recommendations?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"(c) Applicable Government Department or Medical Body or Pharmaceutical Industry Body guidelines?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"(d) E.C. guidelines on Good Clinical Practice?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"(e) I.C.H. Harmonised Tripartite Guidelines?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"If applicable, are all rights of recourse retained against Trial Sponsors and/or Product Manufacturers?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide full details if any","type":"text","label":"Give details of serious adverse events during the last 5 years resulting in death, disease or illness (physical or mental) to research subjects, and any circumstances, which have given or might give rise to a claim against you.","options":[],"required":null,"pdf_field":""},{"help":"Describe the clinical trials planned","type":"text","label":"Full description of Clinical Trials to be conducted","options":[],"required":null,"pdf_field":""},{"help":"Attach these documents for each trial","type":"attachment","label":"For each trial please attach a copy of:","options":["PROTOCOL (or summary thereof) or ETHICS COMMITTEE SUBMISSION","VOLUNTEER CONSENT FORM AND/OR PATIENT INFORMATION (as appropriate)","ANY HOLD HARMLESS AGREEMENT/CONTRACT INDEMNITIES WITH OTHER PARTIES (if applicable)"],"required":null,"pdf_field":""},{"help":"Fill in the table with details of trials performed in last 12 months","type":"table","label":"SUMMARY OF TRIALS PERFORMED IN THE LAST 12 MONTHS: Date Commenced, Trial Title / Description, Phase, No. Of Research Subjects, Current Status","options":[],"required":null,"pdf_field":""},{"help":"Fill in the table with details of planned trials in next 12 months","type":"table","label":"SUMMARY OF TRIALS PLANNED IN THE NEXT 12 MONTHS: Date Commenced, Trial Title / Description, Phase, No. Of Research Subjects, Sponsor","options":[],"required":null,"pdf_field":""},{"help":"Specify indemnity limit per subject","type":"amount","label":"Please state Limits of Indemnity for which a quotation is required or local currency equivalent: Per each Clinical trial Subject","options":[],"required":null,"pdf_field":""},{"help":"Specify total coverage amount per annum","type":"amount","label":"Total coverage Per annum","options":[],"required":null,"pdf_field":""},{"help":"If coverage higher than above, specify amount","type":"amount","label":"If higher, please state","options":[],"required":false,"pdf_field":""},{"help":"Signature of the person completing the form","type":"signature","label":"Signed","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Constitution Details","fields":[{"help":"Select the constitution type and specify if 'Others'","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"}],"deadlines":[],"applies_to":"Clinical Trial Liability Insurance Policy (No Fault Compensation)","attachments":["Protocol Details of the studies","Patient Consent Forms","Compensation agreement/basis (if no fault compensation)","PROTOCOL (or summary thereof) or ETHICS COMMITTEE SUBMISSION for each trial","VOLUNTEER CONSENT FORM AND/OR PATIENT INFORMATION for each trial","ANY HOLD HARMLESS AGREEMENT/CONTRACT INDEMNITIES WITH OTHER PARTIES (if applicable)"],"declarations":["The answers to this form preferably should be typed, or alternatively completed in ink.","All questions must be answered; if not, no quotation will be given.","Completion and signature of this form does not bind the proposer or underwriter to complete a contract of insurance.","If you have insufficient space to complete any answers, continue on headed paper and attach to this form.","It is your duty to disclose all material facts to insurers; a material fact is one likely to influence insurer's judgement and acceptance.","No person shall offer or allow any rebate or commission inducement in respect of insurance policies as per Section 41 of the Insurance Act 1938.","Any person defaulting on rebate provisions shall be liable for penalty up to ten lakhs rupees."],"dropped_labels":1},"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/2508-clinical-trial-liability-insurance-policy-no-fault-compensation-proposal-form"}