Bajaj | Allianz

Policy Details

Line of Business

Product Name *

Account no

Loan Account No

Bank IMD

Branch Sub IMD

Type of Business

Target Date

Bank Customer ID/ CIF No *

Branch Code/Location Code

Employee/LG Code *

Employee/LG Code

LG Name

SP Code *

IR Code

SP Name

IFCS code

Customer Information

Title

Date of Birth *

Bank Customer Id (CIF No.)*

CASA/Loan AC/AAN NO:*

Customer's Gender

Email ID *

Customer Name *

Customer Mobile No*

Address

Pin Code *

Address Line 3(Area)

State

Corresponding Address 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 devices under worldwide coverage

Compulsory Excess - Portable Equipment (Annual policy)

Jewellery

Total value of jewellery ( )

Please provide Jewellery description in the below table.Combined SI will be shown here.

I want to insure jewellery under worldwide coverage

Portable/Non Portable Contents

Non Portable Contents

Description	Age (years)	Value ()	Remove Row

Portable Description*

Age(years)*

Value ( )*

Non Portable 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

Note:-Below 10 lakhs contents(Portable & Non-Portable) sum insured, portable equipment cant be covered

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

C-KYC

PAN Card Number *

C-KYC Number *

C-KYC Status

KYC Link

Lead Status

Lead Sub Status

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*

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