Personal Accident Proposal Form
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1
2For Office Use Only:
Scrutiny No.
Receipt No.
Policy No.
Bajaj Allianz General Insurance Co. Ltd. G.E. Plaza, Airport Road, Yerawada, Pune - 411 006.
For Agent Use Only:
For Agent Use Only:
Loan Account
Emp/LG Code
IMD Code
Sub IMD Code
IMD Name
Mobile No.
Number
PERSONAL ACCIDENT POLICY PROPOSAL FORM
Instructions For Filling Up The Form:-
1.
Please answer all questions in BLOCK letters
2.
The Liability of the Company does not commence until this Proposal has been accepted by the Company and premium has been paid
3.
This Proposal will be the basis of any subsequent policy that we issue to you. It is therefore essential that you provide all the information in this Proposal FULLY AND
ACCURATELY and that you provide us with any and all additional information relevant to risk to be insured or our decision as to acceptance of the risk or the terms
upon which it should be accepted
Proposer Details
1) Full Name:
Title
First Name
Middle Name
Surname
2) Are you an existing Bajaj Allianz Customer: Yes / No If yes, please mention the Policy No: OG________________________________________________________________
3) Gender:
Male
Female
Other
5) PAN No.
4) Date of Birth
6) UID/Unique ID:
7) Bajaj Allianz Employee Code, if Proposer is BAGIC/BALIC Employee
Married
Single
Divorced
Widowed
Sons
Daughters
8) Marital Status:
9) No. of Children
10) Occupation
Business
Salaried
Professional
Student
House Wife
Retired
Others___________________________________
11 a) Permanent / Residential Address
11 b) Correspondence Address:
(All the communications will be sent to the below address)
House
House
House No.
House No.
Name
Name
Landmark/
Landmark/
Locality
Locality
Road/
Road/
Area Name
Area Name
City/District
City/District
Pin Code
Pin Code
State
State
Tel.
Tel.(Res.)
Mobile
Tel.(Office)
Email
Mobile Number
E-Mail
12) Educational Qualification:
Matriculate
Under Graduate
Graduate
Post Graduate
Professionally Qualified
13) Family Monthly Income:
Up to Rs. 20,000
Rs. 20,001 to Rs. 50,000
Rs. 50,001 to Rs. 1 lakh
Above Rs. 1 lakh
14) In case of any Offer, you would prefer to be contacted by:
Phone
Email
15)Nationality
16) Details of the persons to be insured
DOB
Total
Gender
Any Existing
Sr
Age
Occupation
Name
(dd/mm
Premium
Monthly
(M/F)
disability / infirmity
No
/yy)
Income
17) Plan Details
Medical Expenses
Hospital Confinement
Sr
Comprehensive SI
Name Of Insured
Basic SI
Wider SI
(Yes/ No)
Allowance (Yes/ No)
No
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