{"id":2525,"title":"EMPLOYEE'S COMPENSATION INSURANCE POLICY PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/workmens-compensation-insurance-policy/Workmen-Compensation-pf.pdf","sha256":"49441339f8e26e92c7e2d5115eef3f375a91d5eb02e3cc492f273fd7a4e3786f","pages":8,"collected":"2026-10-17","instructions":{"about":"This form is used by employers (proposers) to apply for Employees Compensation Insurance covering their employees against injury or occupational diseases arising out of employment.","notes":["All persons employed must be included in the proposal.","Wages definition includes remuneration and certain benefits as per Employees' State Insurance Act, 1948.","Attach additional sheets if required for employee or contractor details and past claims experience.","Keep policy updated with contact and bank details for faster service.","The proposer must inform the company of any material changes after submission of this proposal.","The form content and particulars must be explained in vernacular to the proposer if required."],"title":"EMPLOYEE'S COMPENSATION INSURANCE POLICY PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details and Policy Information","fields":[{"help":"","type":"text","label":"Proposer's name in full","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Proposer's business [Correspondence] address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Proposer's trade or occupation","options":[],"required":null,"pdf_field":""},{"help":"Describe the work activities to be insured","type":"text","label":"Particulars of work to be covered in Detail","options":[],"required":null,"pdf_field":""},{"help":"Provide address(es) of work locations","type":"text","label":"Risk Location address(s)","options":[],"required":null,"pdf_field":""},{"help":"Specify number and length of shifts","type":"text","label":"Number of work shifts and duration of each shift","options":[],"required":null,"pdf_field":""},{"help":"Start date of insurance coverage","type":"date","label":"Policy Period: From","options":[],"required":null,"pdf_field":""},{"help":"Name as per bank records","type":"text","label":"Bank Details - Name as pr Bank","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name Of Bank","options":[],"required":null,"pdf_field":""},{"help":"Provide bank account number for claim payments","type":"text","label":"Bank Account No.","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSCCode","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"I accept to pay & receive claim amount (if any) in the above given Bank a/c","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide IFSC code for e-Insurance Account if applicable","type":"text","label":"Electronic-Insurance Account: IFSCCode","options":[],"required":false,"pdf_field":""},{"help":"Provide e-Insurance Account number if available","type":"text","label":"Please provide e-lA No. to deposite your insurance policy.","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Do you want to open e-lA account","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Are you an exisiting customer of BGI L?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide existing customer PID number","type":"text","label":"If Yes. Please provide PID No:","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Constitution Details","fields":[{"help":"","type":"yes-no","label":"Partnership Firm","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Limited Liability/Partnership Firm","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide DARPAN registration if NGO/NPO","type":"yes-no","label":"NGO/NPO - Provide DARPAN Portal Registration, if applicable","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Company","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Trust","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Society","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Section 8 Company","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Proprietorship Firm","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify other constitution type if applicable","type":"text","label":"Others (Please specify)","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":"Coverage Options and Limits","fields":[{"help":"Specify limit per accident","type":"amount","label":"Limit Per Accident for any number of Employees (Rs)","options":[],"required":null,"pdf_field":""},{"help":"Specify aggregate limit","type":"amount","label":"Aggregate Limit for all accidents and claims arising there from during the Period of Insurance (Rs)","options":[],"required":null,"pdf_field":""},{"help":"Number of employees covered","type":"number","label":"No of Employees","options":[],"required":null,"pdf_field":""},{"help":"Select if road ambulance coverage is opted","type":"yes-no","label":"Road Ambulance (Rs.5000 Per Employee in the aggregate during the policy period)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select if transportation of mortal remains coverage is opted","type":"yes-no","label":"Transportation of Mortal Remains (Rs.2000 Per Employee in the aggregate during the policy period)","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Employee and Contractor Details","fields":[{"help":"Describe employee categories","type":"text","label":"Description of Employees","options":[],"required":null,"pdf_field":""},{"help":"Number of employees declared","type":"number","label":"Declared Number of Employees","options":[],"required":null,"pdf_field":""},{"help":"Total wages declared for employees","type":"amount","label":"Total Declared wages during the period of insurance","options":[],"required":null,"pdf_field":""},{"help":"Locations of employment","type":"text","label":"Place/Places of Employment","options":[],"required":null,"pdf_field":""},{"help":"Name of contractor if coverage opted","type":"text","label":"Contractors Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the above schedule include (a) All persons in your service?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Safety and Compliance Questions","fields":[{"help":"","type":"yes-no","label":"Do you comply with all statutory obligations, manufacturer's recommendations and other safety regulations in conduct of the Business?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you maintain an accurate record of the Employees and Wages in respect of the Business in compliance with all statutory requirements?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have documented SOP for employee safety in place?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Related to SOP compliance","type":"yes-no","label":"Is there a compliance procedure in place?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is there a procedure in place for identification and immediate correction of breach in SOP for Employee safety?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you carry out periodic management review of SOP?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select all applicable safety measures","type":"checkbox","label":"Fire prevention and safety measures available in your factory/establishment (Fire Extinguisher, Hydrant system, Smoke detection systems, 24 x7 Watch and Ward, Common Watchman)","options":["Fire Extinguisher","Hydrant system","Smoke detection systems","24 x7 Watch and Ward","Common Watchman"],"required":null,"pdf_field":""},{"help":"Select frequency of safety training","type":"choice","label":"Do you carry out frequent training sessions on Safety for your Employees?","options":["Monthly","Quarterly","Half Yearly","Yearly","More than Yearly"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have a medical facility with round the clock doctors, para medical staff and ambulance services?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have a medical facility with round the clock para medical staff and ambulance services, but doctors on call only?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"No medical facility available except first aid","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Hospital (public/private) within 5 k.m. from your factory/establishment with round the clock availability of doctors, para medical staff, ambulance services?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Insurance History and Claims Experience","fields":[{"help":"","type":"yes-no","label":"Has any proposal for an insurance in respect of your liability to your employees or renewal thereof ever been declined?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Has any proposal for an insurance in respect of your liability to your employees or renewal thereof ever been withdrawn?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Consent","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign to confirm all declarations","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"PEP means Politically Exposed Person","type":"yes-no","label":"Are you or any of the proposal applicants a PEP or a close relative of PEP?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Signature of proposer and witness","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":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Witness","options":[],"required":null,"pdf_field":""},{"help":"If yes, provide details and disability certificate","type":"yes-no","label":"Disability Declaration - Any Physical deformity or handicap","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Authorised Representative","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent / Intermediary Declaration","fields":[{"help":"","type":"text","label":"IRDAI COR No./ License No. (Advisor/Corporate Agent/Broker/Relationship Officer)","options":[],"required":null,"pdf_field":""}],"filled_by":"agent"}],"deadlines":[],"applies_to":"Employees Compensation Insurance Policy under Employees Compensation Act 1923","attachments":["Additional sheets if required for employee and contractor details","Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability"],"declarations":["All statements and particulars declared are true and no material fact is suppressed or misrepresented.","The contract of insurance is effective only upon acceptance by the company and receipt of premium.","The proposer agrees to exercise all reasonable safety precautions for employees.","Consent is given to share personal information with group companies for insurance and related services.","No rebates or inducements are allowed as per Section 41 of the Insurance Act 1938.","Premiums are paid from legally acquired sources of income.","Agent/intermediary has explained the form contents to the proposer in vernacular language."],"dropped_labels":23},"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/2525-employee-s-compensation-insurance-policy-proposal-form"}