{"id":2541,"title":"PROPOSAL FORM FOR PLATE GLASS INSURANCE","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/plate-glass-insurance-policy/Plate-Glass-Insurance-Policy-pf.pdf","sha256":"7c365a6f89b8c564a2e5b7187829b8fad472c4d55274cfc9f0795863e5738fc8","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by a proposer (potential policyholder) to apply for plate glass insurance with Bajaj General Insurance Limited. The proposer fills it to provide details about the insured property, previous insurance, and other relevant information for underwriting.","notes":["Answer all questions fully and accurately; failure may lead to claim rejection or policy avoidance.","Use block letters for the proposer name.","Attach separate sheets if space is insufficient.","No rebates are allowed as per the Prohibition of Rebates section.","Keep policy details updated for hassle-free service.","The form includes a declaration about Politically Exposed Persons (PEP).","The proposer must sign and date the form; witness signature is also required.","Agent must fill and sign the agent report section.","The form includes a disclaimer about confidentiality and virus protection for email communications."],"title":"PROPOSAL FORM FOR PLATE GLASS INSURANCE","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details and Bank Information","fields":[{"help":"","type":"text","label":"Agent / Broker:","options":[],"required":null,"pdf_field":""},{"help":"Write your full name in block letters","type":"text","label":"Name of the Proposer (in full) (IN BLOCK LETTERS)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Street No. / House No.","options":[],"required":true,"pdf_field":""},{"help":"Full address of the location to be insured","type":"text","label":"Address of the Insured Location","options":[],"required":true,"pdf_field":""},{"help":"Pin code of the insured location","type":"number","label":"Postal code","options":[],"required":true,"pdf_field":""},{"help":"Describe your business or trade","type":"text","label":"Nature of Business or Trade","options":[],"required":true,"pdf_field":""},{"help":"Select your occupation basis","type":"choice","label":"Basis of occupation of the premises","options":["Trader","Manufacturer","Others (Please specify)"],"required":true,"pdf_field":""},{"help":"Provide bank details for claim payments","type":"text","label":"Bank Details","options":[],"required":null,"pdf_field":""},{"help":"Name as per bank records","type":"text","label":"Name as pr Bank","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name Of Bank","options":[],"required":null,"pdf_field":""},{"help":"Your bank account number","type":"text","label":"Bank Account No.","options":[],"required":null,"pdf_field":""},{"help":"IFSC code of your bank branch","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"Tick to accept claim payments via this bank account","type":"checkbox","label":"* I accept to pay & receive claim amount (if any) in the above given Bank a/c","options":[],"required":true,"pdf_field":""},{"help":"Select your electronic insurance account type","type":"choice","label":"Electronic-Insurance Account:","options":["Trader","Manufacturer","Others (Please specify)"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Proprietor","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Tenant","options":[],"required":null,"pdf_field":""},{"help":"IFSC code for e-lA account","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"Provide your e-lA number","type":"text","label":"Please provide e-lA No. to deposite your insurance policy.","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Do you want to open e-lA account:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide your PID number if existing customer","type":"text","label":"If Yes. Please provide PID No:","options":[],"required":null,"pdf_field":""},{"help":"Provide your policy number if existing customer","type":"text","label":"Policy No.","options":[],"required":null,"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":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Constitution Details","fields":[{"help":"Specify constitution if applicable","type":"text","label":"If Yes Specify Constitution","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Partnership Firm","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Limited Liability/Partnership Firm","options":[],"required":null,"pdf_field":""},{"help":"Tick if NGO/NPO and provide DARPAN details","type":"checkbox","label":"NGO/NPO - Provide DARPAN Portal Registration, if applicable","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Company","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Trust","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Society","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Section 8 Company","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Proprietorship Firm","options":[],"required":null,"pdf_field":""},{"help":"Specify other constitution if applicable","type":"text","label":"Others (Please specify)","options":[],"required":null,"pdf_field":""},{"help":"Provide DARPAN portal registration details if applicable","type":"text","label":"DARPAN DETAILS","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Particulars of Plate Glass to be Insured","fields":[{"help":"Describe position of each glass pane","type":"text","label":"Position of each square of pane of glass","options":[],"required":null,"pdf_field":""},{"help":"Height of glass pane in centimeters","type":"number","label":"Height in cm","options":[],"required":null,"pdf_field":""},{"help":"Declared value of the glass in rupees","type":"amount","label":"Value (Rs)","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"General Questions","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Are the premises situated at the corner of a street or exposed to any special risk?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe special risk if applicable","type":"text","label":"If 'Yes', please give brief description:","options":[],"required":false,"pdf_field":""},{"help":"Select the floor","type":"choice","label":"On which floor are the insured premises situated?","options":["Cellar","Ground Floor/ First floor","Other floor"],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Is there any plate glass in the insured premises that is not included in the schedule?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe the additional plate glass","type":"text","label":"If 'Yes', please give brief description:","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Is there at present any broken or damaged plate glass?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Describe broken/damaged glass details","type":"text","label":"If 'Yes', please describe its position and size:","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Previous Insurance / Previous Damages","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Has any insurance company in respect of plate glass insurance ever declined your proposal?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Has the risk been previously insured?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide Name of Insurance Company, Policy No., Period of Insurance, Rate charged, Any special terms & conditions imposed","type":"table","label":"If Yes, please give the following information:","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Do you have other insurance policies currently? (Fire etc.)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name of other insurance company","type":"text","label":"If Yes, please mention the insurance company","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Do you need cover against riot, strike, terrorist activities on the payment of additional premium?","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Policy Period and Payment Details","fields":[{"help":"Start date of policy","type":"date","label":"Policy period From","options":[],"required":true,"pdf_field":""},{"help":"End date of policy","type":"date","label":"To","options":[],"required":true,"pdf_field":""},{"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 if applicable","type":"choice","label":"Cheque - Given by:","options":["Spouse","Father","Mother","Son/Daughter","Employer/ Employee","Financier"],"required":false,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration and Warranty","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Proposer's signature","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent Report","fields":[{"help":"Date of agent report","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of agent report","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Agent signs here","type":"signature","label":"Signature of Agent","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"},{"title":"Declaration - Physical Proposal Form","fields":[{"help":"Politically Exposed Person status","type":"choice","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":"Consent for KYC verification","type":"choice","label":"I/we hereby give my/our consent to the Company to verify and obtain my/our identity/address proof through Central KYC Registry or Goods and Service Tax Portal or Ministry Of Corporate Affairs Portal or National Securities Depository Limited portal for the purpose of undertaking KYC","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Confirm legal source of premium payment","type":"choice","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":true,"pdf_field":""},{"help":"Consent for sharing personal data","type":"choice","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","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Confirm understanding of updating details","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, to process any of your service requests faster and hassle-free in future.","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Signature of person explaining the form","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":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","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":""},{"help":"Date of witness signature","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of witness signature","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Declare any disability","type":"choice","label":"Disability Declaration: Any Physical deformity or handicap","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide disability details and certificate info","type":"text","label":"If Yes. Please provide details:","options":[],"required":false,"pdf_field":""},{"help":"Authorised representative details","type":"text","label":"I _____ authorised representative of Mr./Miss/Mrs. ___ hereby giving consent on the behalf of the proposer due to his/her disability , that he/she has understood the content of this form and its particulars and confirmed the same","options":[],"required":false,"pdf_field":""},{"help":"Name of authorised representative","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":""},{"help":"Date of authorised representative signature","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Place of authorised representative signature","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"Confirm submission of required documents","type":"checkbox","label":"Claim Docs: 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. 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 license number","type":"text","label":"IRDAI COR No./ License No.(Advisor/Corporate Agent/Broker/Relationship Officer)","options":[],"required":true,"pdf_field":""},{"help":"Agent signs here","type":"signature","label":"Signature of Agent","options":[],"required":true,"pdf_field":""},{"help":"Date of agent signature","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of agent signature","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Agent/IMO name, code and signature","type":"text","label":"Agent / IMO (SP/DP/ BQP) signature and their code","options":[],"required":true,"pdf_field":""},{"help":"SP/BQP/DP/PoS name","type":"text","label":"SP/ BQP /DP/ PoS Name","options":[],"required":true,"pdf_field":""},{"help":"SP/BQP/DP/PoS code number","type":"text","label":"SP / BQP /DP/ PoS CoR No.","options":[],"required":true,"pdf_field":""},{"help":"Signature of SP/BQP/DP/PoS","type":"signature","label":"SP / BQP /DP/ PoS Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"agent"}],"deadlines":[],"applies_to":"Plate Glass Insurance","attachments":["If there is insufficient space in this proposal form for you to provide relevant information, please attach a separate sheet","Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability"],"declarations":["The proposer declares that all statements are true and complete and no relevant information is withheld.","The proposal and declarations form the basis of the contract with Bajaj General Insurance Limited.","The proposer agrees to pay premium and accept policy conditions.","The proposer undertakes to exercise all ordinary and reasonable precautions for safety of the property.","The proposer consents to sharing information within group entities.","The proposer consents to KYC verification through specified portals.","The proposer confirms premium payment from legally acquired sources.","The proposer consents to sharing personal information with group companies for services.","The proposer agrees to keep policy contact and bank details updated for faster service.","The agent declares having explained the proposal form contents in vernacular to the proposer.","The agent confirms that untrue statements or non-disclosure may lead to policy variation or cancellation."],"dropped_labels":6},"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/2541-proposal-form-for-plate-glass-insurance"}