Errors / Warnings
  • Aadhaar no of IP is not validate through ekyc, Kindly do the needful
  • Proposal Form CSC BACHAT PLUS
    Agent Details
    VLE/RAP code * VLE/RAP name
    VLE/RAP State VLE/RAP district IC Code
    STM code STM Name Employee Code
    VLE Mobile Number Sector * Proposal Type
     
    Personal Details
    Aadhar Card * Validate Thru
    Title * Name
    DOB (DD/MM/YYYY) Entry Age
    Gender Nationality Place of Birth
     
    PH Details
    Aadhar Card * Validate Thru
    Title * Name
    DOB (DD/MM/YYYY) Entry Age
    Gender Nationality Place of Birth
     
    PH Address Details
    C/O Landmark Locality
    VTC District House No.
    State Country PINCODE
    E-mail id Mobile No.
    Family Details
    Relation of Proposer to Proposed Insured * Marital Status * If Married, Spouse Date of birth (DD/MM/YYYY)
    Place of Birth *   Father's Name/Husband's Name *
     
    Nominee Details
    Name & Surname * Relationship to Nominee * Date of Birth (DD/MM/YYYY)*
    Place of Birth *
    Name of Appointee Relationship to Nominee Date of Birth (DD/MM/YYYY)
    Place of Birth
     
    Coverage Information
    Policy Term * Premium Term * Premium Amount *
    Premium Frequency * Sum Assured * Total Amount Payable
     
    Bank Details
    IFSC code Bank Name Bank Branch Name
    Account Number Renewal Pay Mode *
     
    Declarations of Good Health of LA
    Yes No
    Are you presently in Good Health? *       
    Height(cms)* Weight(kgs)*
    Occupation *
     
      Yes No  
    Yes No
    Are you currently pregnant??          
    Date of birth of your youngest child if any ? (DD/MM/YYYY)
     
    Declaration
    I hereby declare that I have been explained by the Rural Authorised Person, all the requisite information about the nature of information required in the proposal form by the insurer and also the importance of disclosure of material information in purchase of insurance policy along with consequences of non-disclosure and inaccuracies. I further declare that the information as contained in the proposal form has been filled by Rural Authorised Person on my instructions, which are true, complete, correct and full without any concealment or misstatement and I have affixed my Thumb (Biometric) impression on being fully satisfied with the same. I understand that Bajaj Allianz Life Insurance Company Limited (Company) shall rely and act on them without verification believing them to be true, complete and correct. I undertake to bring to the notice of the Company any discrepancy in proposal form within free look period.
      
    I Agree
      
    Proposal Sign Date (DD/MM/YYYY)