{"id":2602,"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-Form.pdf","sha256":"ae400af704b658a1b55c4987a46221f52d3877134581e47006022a69e13bca38","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by individuals or businesses applying for consequential loss (fire) insurance to provide details about their business, premises, and insurance requirements.","notes":["Answer all questions fully and accurately; failure may lead to claim rejection or policy avoidance.","Attach separate sheets if space is insufficient to provide information.","Use the vernacular explanation provided by the agent if needed.","Keep policy details updated for smooth service.","Original disability certificate required if applicable.","Agent must sign and provide license details.","This form is the basis for the insurance contract."],"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":"Complete 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":"Bank account number for claim payments","type":"text","label":"Bank Account No.","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSCCode","options":[],"required":false,"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":true,"pdf_field":""},{"help":"Provide e-lA number if applicable","type":"text","label":"Electronic-Insurance Account: 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":false,"pdf_field":""},{"help":"IFSC code if existing customer","type":"text","label":"Existin Customer IFSCCode","options":[],"required":false,"pdf_field":""}],"filled_by":"applicant"},{"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":""}],"filled_by":"applicant"},{"title":"Existing Insurance Details","fields":[{"help":"Provide insurer name, policy number, period of insurance, and perils covered","type":"text","label":"If YES, please give the following details of the insurance effected:","options":[],"required":false,"pdf_field":""}],"filled_by":"applicant"},{"title":"Financial and Insurance Coverage Details","fields":[{"help":"Estimated net profit","type":"amount","label":"Net Profit","options":[],"required":true,"pdf_field":""},{"help":"Estimated standing charges","type":"amount","label":"Standing Charges","options":[],"required":true,"pdf_field":""},{"help":"Total gross profit amount","type":"amount","label":"Total (Gross Profit)","options":[],"required":true,"pdf_field":""},{"help":"Proposed sum insured amount","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":"applicant"},{"title":"Customer and Constitution Details","fields":[{"help":"","type":"choice","label":"Are you an exisiting customer of BGIL?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide existing policy or PID number","type":"text","label":"If Yes. Please provide PID No: /Policy No.","options":[],"required":false,"pdf_field":""}],"filled_by":"applicant"},{"title":"Additional Coverage and History","fields":[{"help":"Number of months indemnity period","type":"number","label":"Indemnity period opted","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you require coverage for Supplier's Premises?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"List suppliers with addresses and business dependence percentage","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","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 which utility failures to cover","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":"","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","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","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","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":"applicant"},{"title":"Declarations and Consent","fields":[{"help":"Politically Exposed Persons status","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 updates","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","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":"Name of witness to proposer signature","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":"Declare any physical disability","type":"yes-no","label":"Disability Declaration: Any Physical deformity or handicap","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide disability details and certificate","type":"text","label":"If Yes. Please provide details: (Disability Certificate issued by the Medical Board appointed by the Government for certifying Disability)","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":["Confirmed"],"required":true,"pdf_field":""}],"filled_by":"applicant"},{"title":"Agent/Intermediary Declaration","fields":[{"help":"Agent confirms explanation of form contents","type":"checkbox","label":"I, acting in my capacity as an Insurance Advisor/Specified Person of the Corporate Agent/Authorized Employee of the Broker/Relationship Officer, hereby declare that I have explained all the contents of this Proposal Form, including the nature of the questions contained herein, to the Proposer in their vernacular language, if required.","options":["Declared"],"required":true,"pdf_field":""},{"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 signature","type":"signature","label":"Signature of Agent","options":[],"required":true,"pdf_field":""},{"help":"Agent or IMD code and signature","type":"text","label":"Agent / IMD (SP/DP/ BQP) signature and their code","options":[],"required":false,"pdf_field":""},{"help":"Name of SP/BQP/DP/PoS","type":"text","label":"SP/ BQP /DP/ PoS Name","options":[],"required":false,"pdf_field":""},{"help":"Code of SP/BQP/DP/PoS","type":"text","label":"SP/ BQP /DP/ PoS CoR No.","options":[],"required":false,"pdf_field":""},{"help":"Signature of SP/BQP/DP/PoS","type":"signature","label":"SP/ BQP /DP/ PoS Signature","options":[],"required":false,"pdf_field":""}],"filled_by":"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"],"declarations":["The statements made in the proposal are true and complete to the best of the applicant's knowledge.","The proposal and declarations form the basis of the insurance contract.","The applicant agrees to accept the policy subject to company conditions and pay the premium as quoted.","Consent is given to share information within group entities.","Premiums are paid from legally acquired sources and will continue to be so.","Consent is given for KYC verification through specified government portals.","Consent is given to share personal information with group companies for services and products.","Policyholder must keep contact and bank details updated for faster service.","Agent declares having explained the form contents to the proposer in vernacular if required.","Non-disclosure or untrue statements may lead to policy being void and premiums forfeited."],"dropped_labels":7},"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/2602-proposal-form-for-consequential-loss-fire-insurance"}