{"id":2599,"title":"Proposal Form for CONSEQUENTIAL LOSS (FIRE) INSURANCE","purpose":"proposal","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/commercial-insurance/consequential-loss-fire-insurance-policy/CLFIProposal-Form2.pdf","sha256":"516e9aa507e756b15aebf96ff62fffda1314ae25b611e05037f60c6c4a314100","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is a proposal for consequential loss (fire) insurance to be filled by the insured person or entity seeking insurance coverage.","notes":["Answer all questions fully and accurately.","Attach separate sheets if space is insufficient.","Use vernacular explanation if required.","Keep policy details updated for service requests.","Original disability certificate required if applicable."],"title":"Proposal Form for CONSEQUENTIAL LOSS (FIRE) INSURANCE","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Insured Details and Bank Information","fields":[{"help":"","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Provide full postal address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Telephone no.","options":[],"required":false,"pdf_field":""},{"help":"Name as per bank records","type":"text","label":"Name as pr Bank","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name Of Bank","options":[],"required":false,"pdf_field":""},{"help":"Provide bank account number for claim payments","type":"text","label":"Bank Account No.","options":[],"required":false,"pdf_field":""},{"help":"Indian Financial System Code of the bank branch","type":"text","label":"IFSCCode","options":[],"required":false,"pdf_field":""},{"help":"Confirm acceptance of payment through the given bank account","type":"yes-no","label":"* I accept to pay & receive claim amount (if any) in the above given Bank a/c","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide e-lA number if available","type":"text","label":"Electronic-Insurance Account: Please provide e-lA No. to deposite your insurance policy.","options":[],"required":false,"pdf_field":""},{"help":"Select if you want to open an e-lA account","type":"choice","label":"Do you want to open e-lA account:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"IFSC code if you are an existing customer","type":"text","label":"Existin Customer IFSCCode","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Premises and Business Details","fields":[{"help":"List all premises addresses to be insured","type":"text","label":"Premises to be covered under the policy (Please give complete address, if more than one location all locations to be covered are to be specified)","options":[],"required":true,"pdf_field":""},{"help":"Describe business activities at each location","type":"text","label":"Details of business carried out in each of the locations to be covered","options":[],"required":true,"pdf_field":""},{"help":"Start date of insurance coverage","type":"date","label":"Period of Insurance From","options":[],"required":true,"pdf_field":""},{"help":"Provide details of existing fire insurance if applicable","type":"text","label":"If YES, please give the following details of the insurance effected: (a) Name of the insurer (b) Policy no. (c) Period of insurance (d) Perils covered","options":[],"required":false,"pdf_field":""},{"help":"Propose sum insured amount for loss of profit","type":"amount","label":"Sum insured proposed for Loss of Profit Insurance (Sum insured to be Annual Gross Profit upto 12 months indemnity period and proportionately higher for indemnity period more than 12 months)","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Constitution Details","fields":[{"help":"Indicate if existing customer and provide PID or policy number","type":"text","label":"Are you an exisiting customer of BGIL? Yes No If Yes. Please provide PID No: /Policy No.","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Insurance Coverage Details","fields":[{"help":"Specify indemnity period in months","type":"number","label":"Indemnity period opted","options":[],"required":true,"pdf_field":""},{"help":"Indicate if coverage for supplier premises is required","type":"yes-no","label":"Do you require coverage for Supplier's Premises?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"List suppliers, business dependence percentage and addresses","type":"text","label":"If answer to Qn. 12 is Yes, please give the list of suppliers and percentage dependence of business on each of them along with the addresses of the supplier premises.","options":[],"required":false,"pdf_field":""},{"help":"Provide details of other property locations if coverage extension desired","type":"text","label":"Do you wish to extend coverage to your property stored at other situations? If YES, give details of such locations.","options":[],"required":false,"pdf_field":""},{"help":"Specify extensions required for utility supply failure","type":"text","label":"Do you wish to extend the policy to cover loss due to accidental failure of Public Electricity/Gas/Water supply? If yes mention which extensions are required?","options":[],"required":false,"pdf_field":""},{"help":"Indicate if terrorism cover is required","type":"yes-no","label":"Do you wish to extend cover for Terrorism?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide duration and insurer details of existing loss of profit policy","type":"text","label":"How long you have been availing Loss of Profit policy? Please give details of the insurer for the existing policy.","options":[],"required":false,"pdf_field":""},{"help":"Provide premium and claim history for last 4 years","type":"text","label":"Please give the premium and claim experience for the last 4 years under Loss of Profit cover availed by you?","options":[],"required":false,"pdf_field":""},{"help":"Provide details of any business interruption due to fire/allied perils if not insured previously","type":"text","label":"In case you have not insured for LOP till date, have you experienced any Business Interruption following fire or allied perils for the last 5 years? Please give details","options":[],"required":false,"pdf_field":""},{"help":"Provide details of other insurer approaches or declinations","type":"text","label":"Have you approached any other insurer for this cover? Has any insurer declined/quoted with higher premium for this cover?","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declarations and Consent","fields":[{"help":"Politically Exposed Persons declaration","type":"yes-no","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":"yes-no","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":"Declaration of legal source of premium payment","type":"yes-no","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 information","type":"yes-no","label":"I/We hereby give voluntary consent to BGIL/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":false,"pdf_field":""},{"help":"Acknowledgement of mandatory updated contact and bank 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 proposer and witness with date and place","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":"Declare any physical disability and provide certificate details if applicable","type":"text","label":"Disability Declaration : Any Physical deformity or handicap Yes No If Yes. Please provide details: (Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Confirm submission of all 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":["Confirmed"],"required":true,"pdf_field":""},{"help":"Agent/IMD signature, name and code","type":"signature","label":"Agent / IMD (SP/DP/ BQP) signature and their code","options":[],"required":true,"pdf_field":""}],"filled_by":"insured and agent"}],"deadlines":[],"applies_to":"Consequential Loss (Fire) Insurance policies","attachments":["Separate sheet if insufficient space to provide relevant information","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"],"declarations":["The proposal form and declarations form the basis of the insurance contract.","Failure to provide full and accurate information may result in claim rejection or policy avoidance.","Consent is given to share information within group entities and for KYC verification.","Premiums are declared to be paid from legally acquired sources.","Policyholder must keep contact and bank details updated for faster service.","Agent declares having explained the form contents to the proposer in vernacular language."],"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/2599-proposal-form-for-consequential-loss-fire-insurance"}