{"id":2582,"title":"MACHINERY BREAKDOWN INSURANCE PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/machinery-breakdown-insurance/Machinery-Breakdown-pf.pdf","sha256":"47363daf45f6b4304d6bc53dafa6ed5d83433529a5cedceffb3db8e39dc3ef7c","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for machinery breakdown insurance to be filled by the proposer (policy applicant) providing details about themselves, their machinery, and insurance requirements.","notes":["All questions must be answered completely; if space is insufficient, enclose annexure.","Sum insured must be calculated on present day new replacement value including packing, freight, erection costs, customs duty etc.","Mention if machinery is standby or portable and specify values for foundations or oil if cover is required.","Keep policy contact and bank details updated for faster service.","Use original and relevant documents as required.","Agent/intermediary details and signatures are mandatory."],"title":"MACHINERY BREAKDOWN INSURANCE PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Proposer Details","fields":[{"help":"","type":"text","label":"Proposer’s name","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No; if No, provide name as per Aadhaar Card","type":"choice","label":"Is your name mentioned above as per your Aadhaar Card ? : YES No If No, Please mention the Name as per Aadhaar Card","options":["YES","No"],"required":null,"pdf_field":""},{"help":"Enter Aadhaar Card number","type":"text","label":"Aadhar Card No.","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN Number","options":[],"required":null,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender:  Male Female Other","options":["Male","Female","Other"],"required":null,"pdf_field":""},{"help":"Describe your trade or business","type":"text","label":"Proposer’s trade or business","options":[],"required":null,"pdf_field":""},{"help":"Enter postal address","type":"text","label":"Proposer’s postal address","options":[],"required":null,"pdf_field":""},{"help":"Enter telephone number","type":"phone","label":"Tel. No. :","options":[],"required":null,"pdf_field":""},{"help":"Enter location address of the plant","type":"text","label":"Address where plant to be insured is located","options":[],"required":null,"pdf_field":""},{"help":"Enter name of chief engineer or plant manager","type":"text","label":"Name of chief engineer or plant manager","options":[],"required":null,"pdf_field":""},{"help":"Enter agent name if applicable","type":"text","label":"Agent","options":[],"required":null,"pdf_field":""},{"help":"Enter employee code if applicable","type":"text","label":"Bajaj General Employee code, if proposer is an Employee","options":[],"required":null,"pdf_field":""},{"help":"Enter name as per bank records","type":"text","label":"Bank Details Name as pr Bank","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name Of Bank","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No.","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"Tick to accept payment and receipt of claim amount in above 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 if you are an existing customer","type":"choice","label":"Existing Customer Are you an exisiting customer of Bajaj General? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide PID or Policy number if existing customer","type":"text","label":"If Yes. Please provide PID No: / 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":""},{"help":"Enter e-IA number if available","type":"text","label":"Electronic-Insurance Account: Please provide e-IA No. to deposite your insurance policy.","options":[],"required":null,"pdf_field":""},{"help":"Select if you want to open e-IA account","type":"choice","label":"Do you want to open e-IA account: Yes/No","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Constitution Details","fields":[{"help":"Tick if applicable","type":"checkbox","label":"Partnership Firm","options":[],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Limited Liability/Partnership Firm","options":[],"required":null,"pdf_field":""},{"help":"Tick if applicable and provide DARPAN registration","type":"checkbox","label":"NGO/NPO- Provide DARPAN Portal Registration, if applicable","options":[],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Company","options":[],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Trust","options":[],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Society","options":[],"required":null,"pdf_field":""},{"help":"Tick if applicable","type":"checkbox","label":"Section 8 Company","options":[],"required":null,"pdf_field":""},{"help":"Tick if applicable","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 details of constitution","type":"text","label":"Constitution Details","options":[],"required":null,"pdf_field":""},{"help":"Provide DARPAN details if applicable","type":"text","label":"DARPAN DETAILS","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Machinery and Insurance History","fields":[{"help":"Answer Yes or No","type":"yes-no","label":"Do the items listed represent the whole of the plant ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Are you at present insured ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide insurer name if insured","type":"text","label":"If so, with whom ?","options":[],"required":null,"pdf_field":""},{"help":"Provide details if yes","type":"text","label":"Requested for repairs or made other special stipulations for risk improvement ? If yes, provide details","options":[],"required":null,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Are you aware of any defects/damages existing in the machinery?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of defects/damages","type":"text","label":"If so, give details thereof","options":[],"required":null,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Has your machinery sustained any damage from breakdown or other cause during last 3 years?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of damages and repair costs","type":"text","label":"If so, give details of damages and repairing costs","options":[],"required":null,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Are regular periodical maintenance and/or inspections of the machinery carried out?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of maintenance provider and intervals","type":"text","label":"If so by whom and at what intervals?","options":[],"required":null,"pdf_field":""},{"help":"Answer Yes or No","type":"yes-no","label":"Are the staff fully trained in operating this machinery?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No and provide indemnity limits if Yes","type":"choice","label":"On payment of additional premium do you wish to cover the following/ Escalation amount/percentage If yes, provide limits of indemnity Rs. or %","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration and Signature","fields":[{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Proposer's Signature","options":[],"required":true,"pdf_field":""},{"help":"Select mode of payment and specify if cheque given by someone","type":"choice","label":"Mode of Payment : Cheque - Given by : Cheque DD Cash Other","options":["Cheque","DD","Cash","Other"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declaration - Physical Proposal Form","fields":[{"help":"Select Yes or No","type":"choice","label":"Are you or any of the proposal applicants a PEP or a close relative of PEP*? Yes/ No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if Yes","type":"text","label":"If yes, please share the details","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","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 Yes/ No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","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. Yes/ No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","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, to be used in accordance with their respective privacy policies and subject to appropriate measures being in place to safeguard my/our personal information. Yes/ No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Keep contact and bank details updated","type":"info","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. You can update the same through Caringly yours App, WhatsApp Service, Call Center, Missed Call, SMS, Email, website, agent or nearest branch.","options":[],"required":null,"pdf_field":""},{"help":"Confirm understanding and explanation","type":"checkbox","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":"Enter date","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter witness name","type":"text","label":"Name of Witness","options":[],"required":null,"pdf_field":""},{"help":"Witness signature","type":"signature","label":"Signature of Witness","options":[],"required":null,"pdf_field":""},{"help":"Date of witness signature","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of witness signature","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Disability Declaration : Any Physical deformity or handicap Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide disability details and certificate if applicable","type":"text","label":"If Yes. Please provide details: (Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability)","options":[],"required":null,"pdf_field":""},{"help":"Authorized representative to fill if proposer disabled","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":null,"pdf_field":""},{"help":"Enter name of authorized representative","type":"text","label":"Name of Authorised Representative","options":[],"required":null,"pdf_field":""},{"help":"Signature of authorized representative","type":"signature","label":"Signature of Authorised representative","options":[],"required":null,"pdf_field":""},{"help":"Date of signature","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of signature","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Confirm submission of required documents","type":"info","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":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Agent / Intermediary Declaration","fields":[{"help":"Enter IRDAI or license number","type":"text","label":"IRDAI COR No./ License No.(Advisor/Corporate Agent/Broker/Relationship Officer)","options":[],"required":null,"pdf_field":""},{"help":"Agent to sign here","type":"signature","label":"Signature of Agent","options":[],"required":true,"pdf_field":""},{"help":"Date of agent signature","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of agent signature","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter agent or IMD name","type":"text","label":"Agent/IMD Name","options":[],"required":null,"pdf_field":""},{"help":"Enter agent or IMD code","type":"text","label":"Agent/IMD Code","options":[],"required":null,"pdf_field":""},{"help":"Agent or IMD signature","type":"signature","label":"Agent/IMD Signature","options":[],"required":null,"pdf_field":""},{"help":"Enter SP/BQP/DP/PoS name","type":"text","label":"SP / BQP / DP / PoS Name","options":[],"required":null,"pdf_field":""},{"help":"Enter CoR number","type":"text","label":"SP / BQP / DP / PoS CoR No.","options":[],"required":null,"pdf_field":""},{"help":"Signature of SP/BQP/DP/PoS","type":"signature","label":"SP / BQP / DP / PoS Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"agent"}],"deadlines":[],"applies_to":"Machinery Breakdown Insurance","attachments":["Any annexure if space is insufficient for answers","Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability","Relevant and supporting documents sought by the company for policy issuance and claims processing"],"declarations":["The statements and particulars given are true and complete and form the basis of the contract.","Consent to share information within group entities.","Compliance with Insurance Act 1938 Section 41 prohibiting rebates.","Consent to verify identity/address proof through official portals for KYC.","Premiums paid from legally acquired sources of income.","Consent to share personal information with group companies for services and products.","Declaration that the form content has been explained and understood by the proposer.","Agent declaration that contents have been explained to the proposer and that untrue statements may void the policy."],"dropped_labels":3},"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/2582-machinery-breakdown-insurance-proposal-form"}