Bajaj | Allianz

Policy Details

Line of Business

Product Name *

Division Name *

Type of Business

Target Date

Channel/Vertical Name*

Loan Account No

Employee/LG Code *

Bank Customer ID/ CIF No *

SP Code *

LG Name

Customer Information

Customer's Gender

Date of Birth *

CASA/Loan AC/AAN NO:*

Customer Name *

Email ID *

PAN NUMBER:*

Monthly Income*

Title

Customer Mobile No*

Address

Pin Code *

Address Line 3(Area)

State

Corresponding Addess same as Permanent Address

Address Line 1 *

Area (as per PF)

Address Line 2 *

City

Subject Matter

Subject Matter-My Home All Risk

Accomodation Type

Plan

Policy Tenure

Building Type

Age of Building (in yrs)

Type of Plan for Structure

Building

Built up area (in sq. ft.) (A)*

Construction cost ( /sq. ft.) (B)*

Total value of building ( A * B)

I want to insure the content including portable devices based on*

Please enter the value of Non portable contents ( )*

Please enter the value of portable contents ( )*

I want to insure portable devices under worldwide coverage

Compulsory Excess (Annual policy)

Jewellery

Total value of jewellery ( )

I want to insure jewellery under worldwide coverage

Description	Age (years)	Value ()	Remove Row

Description*

Age(years)*

Value ( )*

Jewellery

Description	Quantity	Weight (gms.)	Market Value ()	Remove Row

Description*

Quantity*

Weight(gms.)*

Value ( )*

Is your home financed by any bank \ financial institution?*

Name of the bank / Financial Institution*

Bajaj Allianz - HDFC LMS

Global Personal Guard

Policy Tenure

Select Members*

Gross Monthly Income*

Pre-existing Disease*

Death Sum Insured(Rs)*

Occupation*

Accidental Hospitalization Expenses

Hospital Cash/Anciliary: Per Day Benefit

Loan Protector Cover

Fracture Care

Children Education Benefit

Coma due to accidental injury

EMI Payment Cover

Road Ambulance Cover

Hospital Cash/Anciliary: Per Day Benefit

Hospital Cash/Anciliary: Number of Days

Loss of Income due to Disability from Accident: Weekly Benefit Max 100 weeks

Loss of Income due to Disability from Accident: Sum Insured

Bajaj Allianz - Family Health Care

Family Health Care

FHC+ Health Prime Rider

Inpatient Hospitalisation Treatment: Plan

GOLD

Inpatient Hospitalisation Treatment: Sum Insured

Self Select Members Floater

Bajaj Allianz - Extra Care Plus

Extra Care Plus

Coverage Details

Self Covered

Family Members Combinations

occupation

Customer Name*	Relation*	Gender*	Height(cms)*	Weight(Kg)*	DOB*	Nominee Name*	Nominee Relation*	Pre existing disease*

Customer Name*	Relation*	Gender*	Height(cms)*	Weight(Kg)*	DOB*	Nominee Name*	Nominee Relation*	Pre existing disease*

Customer Name*	Relation*	Gender*	Height(cms)*	Weight(Kg)*	DOB*	Nominee Name*	Nominee Relation*	Pre existing disease*

Customer Name*	Relation*	Gender*	Height(cms)*	Weight(Kg)*	DOB*	Nominee Name*	Nominee Relation*	Pre existing disease*

Customer Name*	Relation*	Gender*	Height(cms)*	Weight(Kg)*	DOB*	Nominee Name*	Nominee Relation*	Pre existing disease*

Customer Name*	Relation*	Gender*	Height(cms)*	Weight(Kg)*	DOB*	Nominee Name*	Nominee Relation*	Pre existing disease*

Policy Level Coverage

Inpatient Hospitalization Treatment :Sum Insured*

Aggregate Deductible*

Policy Period*

Add-on-Policy Level Coverage

Air Ambulance Cover*

Air Ambulance:Sum Insured

Health Prime Rider

Bajaj Allianz - Family Health

Policy Level Coverage

Critical Illness Cover : SI

Inpatient Hospitalization Treatment: Sum Insured

Education Grant: SI

Public Liability: SI

Occupation

Voluntary Copayment

Critical Illness Loading %

Inpatient Hospitalization Treatment: Plan

Householders Content : SI

Policy Period

Hospital Cash: SI

Personal Accident Cover

Travellers Baggage: SI

Zone

Members Combination

Final Premium

Reference ID

Lead Status

Lead Sub Status

Coverages under the policy:
1. In-patient Hospitalisation Treatment 2. Pre-Hospitalisation 3. Post-Hospitalisation 4. Road Ambulance 5. Day Care Procedures, Organ Donor Expenses
6. Sum Insured Reinstatement Benefit 7. Hospital Cash Benefit 8. Preventive Health Check Up 9. Ayurvedic / Homeopathic Hospitalization Expenses

Do you or any of the family members who need to be covered have/had any health complaints, have met with an accident or were hospitalised in the period prior to taking this policy?* Yes NO Are you or any of the family members to be covered under any form of mediation for any illness/diseases?* Yes NO

Declaration I have understood the Coverage & Benefits payable under the plan and the insurance plan opted by me is on a voluntary basis and is as per my requirement* I have read and understood the features of policy and agree to proceed with my application*

Payment Via Credit Card Payment Via Netbanking/Debit Card

Select here and your insurance will never expire ! Yes NO

This is an auto renewal option, we will renew your policy before it expires by auto debiting your current mode of premium payment(applicable only on credit card).
You can cancel this auto renewal any time before your policy expires.

Status Quote Generated

Policy Details

Customer Information

Address

Corresponding Address

Subject Matter

Subject Matter-My Home All Risk

Building

Contents

Jewellery

Contents

Jewellery

Global Personal Guard

Family Health Care

GOLD

Policy Level Coverage