PORTABILITY FORM
PART I
1) Name of the Policyholder / insured (s)____________________________________________________________________________________________________
2) Date of Birth / Age ____________________________________________________________________________________________________________________
3) Address of policyholder /insured ________________________________________________________________________________________________________
4) Details of existing insurer
i. Name of the product_________________________________________________________________________________________________________________
ii. Sum Insured_______________________________________________________________________________________________________________________
iii. Cumulative Bonus__________________________________________________________________________________________________________________
iv. Add ons/Riders taken________________________________________________________________________________________________________________
v. Policy Number______________________________________________________________________________________________________________________
5) Details of the proposed insurance
i. Name of the product proposed/intended to take____________________________________________________________________________________________
ii. Sum insured proposed_______________________________________________________________________________________________________________
iii. Whether Cumulative Bonus to be converted to an enhanced sum insured_______________________________________________________________________
6) Reason (s) of portability________________________________________________________________________________________________________________
7) No of family member to be included in the policy to be ported __________________________________________________________________________________
Period of Insurance First
Details of Previous Health Health ID
Sum Policy
First Name of Insured Card CB From To
Insurance Policy / Policy No. Insured inception
number dd/mm/yyyy dd/mm/yyyy date
Enclosure: Photocopy of the existing policy documents
Signature of Proposer
Date
I
PART II
1. Whether the PED exclusions / time bound exclusion have longer exclusion period than existing policy Yes / No
(Please indicate Yes /No)
2. If yes , please give written consent to the declaration below:
"I am aware that the waiting period for the following disease (s)/ treatment (s) is …..days/years more than the previous policy terms, I hereby agree to observe the
additional waiting period for the following diseases (s)/ treatments (s)
Signature of Policyholder
Bajaj Allianz General Insurance Co. Ltd.
DECLARATIONS – PHYSICAL PROPOSAL FORM
Are you or any of the proposal applicants a PEP* or a close relative of PEP*?
If yes, please share the details
“Politically Exposed Persons” (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign country, e.g.,
Heads of States/Governments, senior politicians, senior government/juridical /military officers, senior executives of state-owned corporations,
important political party officials, etc.” Yes / No
I/we hereby give my/our consent to the Company to verify and obtain my/our identity/address proof through CERSAI records or National
Securities Depository Limited Portal for the purpose of undertaking KYC verification. Yes / No
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
I/We hereby give voluntary consent to BAGIC/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