Can this form be signed electronically?

Yes. Electronic signatures are legally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided the signer consents and the record meets retention and attribution requirements.

Are health disclosures allowed electronically?

Health data may be collected electronically but must comply with HIPAA privacy and security rules; a Business Associate Agreement is required when a vendor processes PHI.

What happens if I need to correct submitted information?

Submit an amended proposal or written correction as directed by the insurer; retain both versions and a clear audit trail showing who made changes and when.

Is notarization required for every submission?

Not generally required for all proposals; specific endorsements or document types may need notarization or witness signatures depending on state law or insurer policy.

How long does underwriting typically take?

Simple risks often resolve within 7–14 business days; complex submissions requiring inspections, medical reports, or third-party verifications take longer.

How is signer identity verified for eSign?

Common methods include email with OTP, SMS code, knowledge-based authentication, or stronger identity proofing for high-risk transactions; stronger methods reduce fraud risk.

Electronic Signature
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Bajaj Allianz Insurance Proposal Form

Bajaj Allianz Insurance Proposal Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

PROPOSAL FORM
WORKMEN'S COMPENSATION INSURANCE

THE INDIAN WORKMEN'S COMPENSATION ACT 1923. The Act provides for the payment of compensation by the Employer to his Employees (for their dependents in the event of fatal accidents) if personal injury is caused to them by accidents arising out of and in the course of their employment.

The maximum compensation payable is upon the following scale (as per W.C. Amendment Act 2000)

Fatal Injury 4,57,080

Permanent Total Disablement 5,48,496

Permanent Partial Disablement According to incapacity

Temporary Disablement Half monthly compensation

THE INDIAN FATAL ACCIDENTS ACT, 1855. This Act, enables claims for damages upto an unlimited amount to be maintained against a person who by his wrongful act, neglect or default causes the death of another.

THE COMMON LAW. The Common Law gives a person the right to claim from another for damage upto an unlimited amount, for injury or loss sustained on account of the negligence of such other person or of his employee acting in the scope of their employment.

THE RESPONSIBILITY OF THE EMPLOYER IS THEREFORE SERIOUS AND ONE THAT COULD LEAD TO A HEAVY FINANCIAL BURDEN IF NOT COVERED BY INSURANCE.

Bajaj Allianz General Insurance Company Limited policies give an Employer any of the following two forms of cover:

Table A: Indemnity against the Employers legal liability to his Employees under the Indian Workmen's Compensation Act, 1923, and subsequent Amendments of the said Act prior to the date of issue of the policy, under the Indian Fatal Accidents Act, 1855, and at common Law.

Table B: Indemnity against the Employers legal liability to his Employees under the Indian Fatal Accidents Act, 1855 and at common law.

The insurance under table “A” can be extended by charging an additional premium of 50% of book rate to cover disease mentioned in part “C” of schedule III of Workmen's Compensation Act.

This insurance does not cover any interest and/or penalty which may be imposed on all insured or an insured on account of failure to comply with the requirements of the said Workmen's Compensation Act, 1923 as amended.

In Addition, the company bears the costs and expenses incurred with its written consent in the settlement of claims

Agent

Client Code

Proposer's Details

1. a. Proposer's Name (in full)

b. Business Address (in full)

c. Tel No. (O)

Mobile

d. Trade or Occupation

e. Particulars of Work

f. Period of Insurance From

To

General Note

The earnings declared must include all salaries, wages, bonuses, tips and overtime payments or other special remuneration received by an employee and the actual value of food, fuel, and quarters or similar allowances in kind.

Description of Employees	Number of Employees	Estimated Annual Salaries/Wages & Other Earnings	Insurance Required State A or B
Workmen drawing monthly wages upto Rs 2000: Clerical Staff
Commercial Travellers
Employees engaged with wood working machinery including machinists and machinists labourers
Workmen drawing monthly wages over Rs. 2000: Clerical staff
Commercial Travellers
Employees engaged with wood machinery including machinists and machinists labourers

The total amount of salaries, wages and other earnings paid by me/us to the above mentioned workmen during the past twelve months was Rs

Do you wish to insure your liability under the Indian Workmen's Compensation Act, 1923 and subsequent amendments of the said Act, prior to the date of issue of the Policy, to the workmen of contractors? If so, please state:

Name of Contractor	Nature of work subject	If contract for labour and materials state estimated amount of contract	In cases for which the contract is for labour only state estimated amount of contract	In case the contract is labour materials and equipments, state estimated amount of contract

The Workmen's Compensation Act 1923, states that where any person (the “Principal”) in the course of or for the purposes of his trade or business contracts with any other person (the “Contractor”) for the execution by or under the contractor of the whole or any part of the work which is ordinarily part of the trade or business of the principle, the latter is liable in respect of accident to the Contractor's workmen happening or in or about the premises on which the Principal has undertaken or usually undertakes to execute the work and who are otherwise under his control or management. In such cases the Principal is indemnified by the Contractor.

PUT A MARK WHEREVER APPLICABLE

All the questions to be answered completely. In case of shortage of space kindly enclose the information as an annexure:

1. Does the above Schedule include a. All persons in your service b. All your Sub Contractors	Yes Yes
2. Are your premises a Factory within the meaning of the Factory Act?	Yes No
3. Have you carried out all the obligations imposed on you by any Law or Regulation governing the conduct or maintenance of such premises?	Yes No
4. a. Have you any circular saws or other machinery driven by steam, gas, water, electricity or other mechanical power? If yes give full particulars b. Are your machinery, plant and ways properly fenced and guarded and otherwise in good order and condition?	Yes No
5. a. What boilers do you have?
5. b. Is it registered under the Indian Boiler Act?	Yes No
5. c. If not, under what conditions is it exempted from such registration?
6. State what acids, gases, chemicals or explosives will be used and to what extent?
7. a. Are you at present insured, or have you ever proposed for an insurance in respect of your liability to your Employees? If so, please state name of Company	Yes No
7. b. Has any such proposal or renewal ever been declined or withdrawn?	Yes No
7. c. Have any of your employees had an accident or suffered injury from their work in the past three years? If yes, please supply details.
8. Do your employees use normal safety devices like safety belts, helmet, gloves, eye glasses during the course of their normal duty	Yes No

Declaration

I/We declare that the above answers are true and to the best of our knowledge and belief and that I/we have disclosed all particulars affecting the assessment of the risk.

I/We agree to render at the end of each period of insurance a statement, in the form required by the Company, of all wages actually paid and to pay premium on any wages paid in excess of the amount estimated above. I/We agree that this proposal shall be the basis of the contract between me/us and the Company and shall be deemed to be incorporated in such contract and any renewal thereof which may be agreed subject to the terms and conditions of the policy issued by the Company. I/We also confirm that I/we have disclosed all material facts likely to influence the acceptance and assessment of the proposal, and I/we detail below additional information not specifically requested which I/we consider should be disclosed to underwriters.

Date

Proposer's Signature

This insurance will not begin until this proposal has been accepted by the Company and evidence of the cover has been issued. A policy specimen may be provided on request.

The following is the copy of section 41 of the Insurance Act 1938

PROHIBITION OF REBATES

1. No person shall allow or offer to allow either directly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India any rebate of the whole or part of the commission payable or any rebate of the premium shown in the policy nor shall any person taking out or renewing or continuing a policy except such rebates as may be allowed in accordance with the published prospectus or tables of the insurer.

2. Any person making default in complying with the provision of this section shall be punishable with a fine, which may extend to five hundred rupees.

What the Bajaj Allianz Insurance Proposal Form Is and when it's used

The Bajaj Allianz Insurance Proposal Form is a structured application used to request insurance coverage, document applicant details, disclose risk factors, and present desired sums insured. It collects personal and risk-specific data, medical history or property information where applicable, premium payment preferences, and declarations required for underwriting. Insurers and agents rely on the form to start underwriting, price risk, and verify eligibility; accuracy at submission reduces underwriting delays and helps ensure the proposal is processed correctly.

Why a clear, complete proposal form matters

A fully completed proposal form speeds underwriting, reduces follow-up requests, and improves the accuracy of premium calculations. It creates a complete record for future claims and regulatory review.

Who prepares and who signs the proposal form

Typical parties who prepare or sign the Bajaj Allianz Insurance Proposal Form.

Policy applicant: Provides personal details, risk answers, and signs declarations to confirm accuracy.
Insurance agent or broker: Completes distribution fields, records product code, and submits on the applicant's behalf.
Underwriter/insurer: Reviews submitted proposals, requests clarifications, and issues quotations or refusals.

Each signer must have authority to certify the answers; mismatches in signer identity can delay acceptance.

Core sections you will find on the form

A professional proposal form groups information so underwriters can evaluate risk quickly and consistently.

Applicant Details

Full legal name, date of birth, contact information, and taxpayer ID or national identification number required for identity checks and premium calculations.

Risk Description

Detailed description of the insured item or exposure, including property location, business activity, or vehicle details to determine coverage applicability.

Coverage Requested

Requested sum insured, limits, deductibles, and any optional endorsements or riders that change the scope of protection.

Medical / Loss History

Prior claims, medical history, or loss runs provide underwriting context and affect eligibility and pricing.

Declarations

Applicant attestations, disclosure of material facts, and consent for data verification and premium collection.

Attachments

Supporting documents such as ID, proof of address, property photos, inspection reports, or medical records when required.

Essential data elements and short-format guidance

Date of Birth: MM/DD/YYYY

Contact Phone: Include country code

Taxpayer ID: SSN or TIN where applicable

Email Address: Used for electronic delivery

Policy Type: Select from provided options

Agent ID: Enter license or producer number

Step-by-step process for completing the proposal

Follow these sequential steps to prepare a submission that underwriters can process without routine clarifications.

01

Gather documents: Collect IDs, prior policies, loss history, and supporting evidence.
02

Complete fields: Fill every required field using the formats noted on the form.
03

Review and sign: Verify all answers, sign, and date before submission.
04

Submit to insurer: Send via the agent portal, email, or the insurer's intake channel.

Where and how completed proposals are sent

Use the route that matches your role—applicants, agents, and underwriters typically use different submission channels.

Agent Portal: Agents upload completed proposals and attachments for direct underwriting intake.
Company Email: Some offices accept secure email submissions with password-protected attachments.
Branch Office: In-person submission to a local branch where available; originals may be requested.
eSubmission API: Large brokers use API-based submission for bulk or automated proposal flows.

Technical formats and platform expectations for electronic submissions

Confirm file types and authentication methods before uploading to avoid rejected submissions.

Accepted Formats: PDF, DOCX, and scanned images are commonly accepted.
Authentication: Email verification or SMS OTP is typical for signer confirmation.
Integrations: CRMs and document management systems like Salesforce and Google Workspace are often supported.

If you use an eSignature provider, ensure it supports required authentication, audit trails, and file formats for regulatory review.

Key timelines and typical processing expectations

Be aware of timing constraints that affect coverage start, underwriting, and premium billing to avoid unintended gaps.

Submission before coverage:

Submit proposals before the desired effective date to allow underwriting to complete.

Underwriting turnaround:

Simple cases often complete within 7–14 business days; complex risks take longer.

Premium payment timing:

Payment is typically due on or before policy inception to bind coverage.

Document corrections:

Respond to underwriter queries promptly—delays extend processing times.

Policy issuance:

Issued after acceptance and receipt of required payment or premium deposit.

Common mistakes that delay or invalidate proposals

Incomplete fields: Leaving required fields blank often triggers requests for clarification and slows underwriting significantly.
Inaccurate risk descriptions: Misstating property details or business activity can lead to declination or rescission later.
Mismatched identity data: Names or IDs that do not match government documents cause verification failures and processing delays.
Missing attachments: Omitting inspection reports, prior policy declarations, or medical records commonly results in provisional quotes or rejection.

Consequences of errors or omissions on the proposal

Policy denial: Underwriter may refuse coverage

Claim rejection: Material misstatements can void claims

Premium adjustment: Incorrect risk info may increase premium

Legal exposure: False statements can result in contract disputes

Regulatory breach: Noncompliance with disclosure rules

Data privacy risk: Improperly handled health data breaches HIPAA

How the proposal form differs from related insurance documents

Compare common insurance documents to understand purpose and evidentiary weight.

Document Type	Purpose	Binding?
Proposal Form	apply for coverage
Insurance Policy	contract of insurance
Claim Form	request payment
Broker Quotation	indicative premium

eSignature vendor snapshot for submitting insurance proposals

Common vendor attributes for eSignature platforms used to submit proposal forms; signNow is listed first per comparison convention.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about using the proposal form

Answers to common questions about validity, signatures, attachments, updates, and processing for the Bajaj Allianz Insurance Proposal Form.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are legally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided the signer consents and the record meets retention and attribution requirements.
Are health disclosures allowed electronically?
Health data may be collected electronically but must comply with HIPAA privacy and security rules; a Business Associate Agreement is required when a vendor processes PHI.
What happens if I need to correct submitted information?
Submit an amended proposal or written correction as directed by the insurer; retain both versions and a clear audit trail showing who made changes and when.
Is notarization required for every submission?
Not generally required for all proposals; specific endorsements or document types may need notarization or witness signatures depending on state law or insurer policy.
How long does underwriting typically take?
Simple risks often resolve within 7–14 business days; complex submissions requiring inspections, medical reports, or third-party verifications take longer.
How is signer identity verified for eSign?
Common methods include email with OTP, SMS code, knowledge-based authentication, or stronger identity proofing for high-risk transactions; stronger methods reduce fraud risk.

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