For Office Use Only: For Agent Use Only:

Scrutiny No. Receipt No. Policy No. IMD Code IMD Name
Relationship Beyond Insurance

BAJAJ ALLIANZ INDIVIDUAL CYBER SAFE INSURANCE POLICY : PROPOSAL FORM

Important: This proposal for insurance will be the basis of any subsequent insurance policy that Bajaj Allianz General Insurance Company Ltd [“Company”] issue to you. It is essential that you answer fully
and accurately all of the questions contained in this proposal, and that you provide us with any and all additional information relevant to the risk to be insured or our decision as to the acceptance of the risk or
the terms upon which it should be accepted. Your failure to comply with this obligation now may result in the rejection of your claim and the avoidance of your policy when a claim is made. If you are in any
doubt about the information to be given, please seek the advice and guidance of your insurance advisor or agent. If there is insufficient space in this proposal for you to provide relevant information, whether
as requested or otherwise, please attach a separate sheet to this proposal and return it to us.
PROPOSER DETAILS
1. Name of the Proposer (in full)

Is your name mentioned above as per your Aadhaar Card? :   YES   NO If No, Please mention the Name as per Aadhaar Card__________________________________
_______________________________________________________________________________________________________________________________________

2. UID/Aadhaar no: 3. PAN No.

4. Gender: Male ☐ Female ☐ 5. Date of Birth: 6. Marital Status: Married ☐ Single ☐

7. Address for Communication

State

Pin Code Mobile Number

E mail ID
8. Occupation: Business/ Self Employed ☐ Service ☐ (If service, then Desk Job ☐ Field Job ☐ ) Student ☐ House wife ☐ Retired ☐ Unemployed
9. Highest Education Completed: Graduate and Above ☐ 12th Pass ☐ 10th Pass ☐ Upto 10th
10. Period of Insurance: From: To:
11. Please answers the following questions
Questions
a. How many computer systems including digital devices do you own, lease or operate?
b. Do you use same Computer System/Device for personal as well as official use? (Please   Yes or No) ☐ YES ☐ NO
c. Does the Computer System including all digital devices that you own, lease or operate has internet facility?
(Please   Yes or No) ☐ YES ☐ NO
c.i. If yes please provide service provider details.
c.ii. Do you actively implement the best network security practices recommended by your service provider such as strong ☐ YES ☐ NO
passwords, two factor authentications, regularly changing your passwords? (Please   Yes or No)
d. Does the Computer System including all digital devices that you are using have an Antivirus software installed on it? ☐ YES ☐ NO
(Please   Yes or No)
d.i. If yes please provide details of Anti-Virus software installed
d.ii. Is the antivirus software updated as per the recommendations of antivirus software service provider? ☐ YES ☐ NO
(Please   Yes or No)
e. Do you maintain up to date patch states of the Operating System (O.S.), browser, and E-Mail Programs and any other ☐ YES ☐ NO
software installed on your Computer System including all digital devices? (Please   Yes or No)
f. Do you maintain regular backup of data on either cloud/external device for your Computer System including all ☐ YES ☐ NO
digital devices? If yes please provide details. (Please   Yes or No)
g. What is your expected monthly average internet usage? ☐ Less than 1 GB
☐ 1.01 GB to 2 GB
☐ 2.01 GB to 4 GB
☐ 4.01 GB to 8 GB
☐ More than 8 GB
h. What is the average time spent by you on the internet usage daily? ☐ Less than 30 Minutes
☐ Upto 1 Hour
☐ 1 Hour to 3 Hours
☐ Above 3 Hours

10. Are you active in social media?(Please   Yes or No) ☐ YES ☐ NO

If yes please give details of Social Media Accounts held by you___________________________________________________________________________________________
11. Have you been a victim of cyber Identity Theft in the past?(Please   Yes or No) ☐ YES ☐ NO
a. If answer to above question is yes, please give details _____________________________________________________________________________________________
b. Did you report the occurrence of the cyber Identity Theft to the Police Authorities?(Please   Yes or No) ☐ YES ☐ NO
c. Was any claim lodged on you by a third party arising out of the cyber Identity Theft?(Please   Yes or No) ☐ YES ☐ NO
d. If answer to above question is yes, give details of claim lodged on you ________________________________________________________________________________
e. Has any case been filed against you in a court of law by a third party arising out of a cyber identity theft?(Please   Yes or No) ☐ YES ☐ NO
f. If answer to above question is yes, give details of the case and the present status ________________________________________________________________________
g. Have you filed any case against a third party in the court of law for committing identity theft?(Please   Yes or No) ☐ YES ☐ NO
h. If answer to above question is yes, give details and the present status_________________________________________________________________________________
12. Have you been a victim of Cyber Stalking in the past?(Please   Yes or No) ☐ YES ☐ NO
a. If answer to above question is yes, please give details _____________________________________________________________________________________________
b. Have you filed any case against a third party in the court of law for committing Cyber Stalking?(Please   Yes or No) ☐ YES ☐ NO
c. If answer to above question is yes, give details and the present status_________________________________________________________________________________
13. Have you paid wrongfully or erroneously any funds due to IT Theft?(Please   Yes or No) ☐ YES ☐ NO
If answer to above question is yes, give details of loss__________________________________________________________________________________________________
14. Have you been a victim of Malware attack in the past?(Please   Yes or No) ☐ YES ☐ NO
a. If answer to above question is yes, give details of loss and expense incurred by you towards cost to restore your computer system and to technically restore, retrieve,
reinstall data or computer program____________________________________________________________________________________________________________
b. Was any claim lodged on you by a third party arising out of the Malware attack of your Computer System?(Please   Yes or No) ☐ YES ☐ NO
c. If answer to above question is yes, give details and the present status_________________________________________________________________________________
15. Have you been a victim of Phishing or E-Mail Spoofing in the past?(Please   Yes or No)
a. If answer to question is yes, give details financial loss suffered by you if any____________________________________________________________________________
b. Have you filed any case against a third party in the court of law for committing Phishing or E-Mail Spoofing?(Please   Yes or No) ☐ YES ☐ NO
c. If answer to above question is yes, give details and the present status_________________________________________________________________________________
16. Have you been a victim of Media Wrongful Act in the past?(Please   Yes or No) ☐ YES ☐ NO
a. If answer to above question is yes, give details of Media Wrongful act alleged to have been committed by you_________________________________________________
b. Has any third party filed any case against you for alleged Media Wrongful Act?(Please   Yes or No) ☐ YES ☐ NO
c. If answer to above question is yes, give details and the present status_________________________________________________________________________________
d. Have you filed any case in the court of law against any third party for committing the Cyber Attack resulting in alleged Media Wrongful Act on your part?
(Please   Yes or No) ☐ YES ☐ NO
e. If answer to above question is yes, give details and the outcome of the case___________________________________________________________________________
17. Have you been a victim of Data Breach or Privacy Breach in the past?(Please   Yes or No) ☐ YES ☐ NO
a. If answer to question is yes, give details of third party from whose computer system your Data Breach or Privacy Breach has taken place ___________________________
________________________________________________________________________________________________________________________________________
b. Have you filed any case against a third party in the court of law for Data Breach or Privacy Breach?(Please   Yes or No) ☐ YES ☐ NO
c. If answer to above question is yes, give details and the present status_________________________________________________________________________________
18. Please select from the following plans:
Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6 Plan 7 Plan 8 Plan 9 Plan 10
Insuring Clause Limit of Indemnity
1 Lac 3 Lac 5 Lac 10 Lac 15 Lac 20 Lac 25 Lac 50 Lac 75 Lac 100 Lac
1.1 Identity Theft Cover 10% of Limit of Indemnity of the plan opted
1.2 Social Media Cover 10% of Limit of Indemnity of the plan opted
1.3 Cyber Stalking 10% of Limit of Indemnity of the plan opted
1.4 IT Theft Loss Cover 25% of Limit of Indemnity of the plan opted
1.5 Malware Cover 10% of Limit of Indemnity of the plan opted
1.6 Phishing Cover 25% of Limit of Indemnity of the plan opted
1.7 E-mail Spoofing 15% of Limit of Indemnity of the plan opted
1.8 Media Liability Claims Cover 10% of Limit of Indemnity of the plan opted
1.9 Cyber Extortion Cover 10% of Limit of Indemnity of the plan opted
1.10 Privacy Breach and Data 10% of Limit of Indemnity of the plan opted
Breach by Third Party
Extension IT Consultant Services Cover 2500 5000 7500 10000 12500 15000 17500 20000 25000 25000
Please mention the plan opted
19. Are you aware at the time of proposal of any prior act, event or circumstances which is likely to give rise to a claim under any of the above insuring clauses?
(Please   Yes or No) ☐ YES ☐ NO
20. Are you presently insured against cyber risk?(Please   Yes or No) ☐ YES ☐ NO
If answer to above question is yes, give details of existing policy/policies if any______________________________________________________________________________
21. Has any company/Insurer in respect of Insurance
Declined your Proposal?(Please   Yes or No) ☐ YES ☐ NO
Cancelled or refused to renew your policy?(Please   Yes or No) ☐ YES ☐ NO
Accepted your proposal on special terms and conditions?(Please   Yes or No) ☐ YES ☐ NO
Declaration
I/We hereby declare on behalf of proposer and on behalf of all persons proposed to be insured that the above statements, declaration, warranties and or particulars given by me are true and
complete in all respects to the best of my knowledge and belief. I/We am/are authorized to propose on behalf of these other persons. I understand that the information provided by me will form
the basis for of the insurance policy and is subject to the Board approved underwriting policy of the Company. I/we have understood that the statements and particulars given in this proposal
form and this declaration shall be held to be promissory and shall be the basis of the insurance contract between me/us and the Bajaj Allianz General Insurance Company Ltd [Company] and the
Insured Beneficiary/Group Member and that, if it is found that any of the statements or particulars in this proposal form or other documents are incorrect, untrue, suppressed any information or
provided misleading/false information in any respect on any material/ immaterial facts/particulars, to the grant of a cover or otherwise, the Company shall have no liability under the insurance
contract or the policy document thereunder, apart from Company's right to cancel my/our policy and the premium paid by me/us shall be forfeited by the Company. I/we also do hereby agree
DECLARATION
and undertake to immediately inform the Company any changes in this proposal form/documents/ risk proposed for insurance after the submission of this proposal form. I/we do hereby agree
to accept the Standard Terms and Conditions and form of the policy issued by Company in such cases. I/We hereby authorize company that all Standard Terms & Conditions of policy can be
displayed in the website of company that enables access by me/us if I/We want to know the terms and conditions of policy displayed on website.
This proposal form is also deemed to be proposal form for renewal of cover, from time to time. I/we also agree that the contract of Insurance will be effective only upon Company conveying its
acceptance of this proposal, and Company actually receiving or realising [in case of payment by cheque/DD/PO] of prescribed full premium amount, failing which Company's risk is void ab initio.
The salient features of the policy, terms and conditions of this proposal have been explained to me/us in vernacular language, and I/We agree to the same. (Please tick in case same is agreed).
Date ____ / ____/ _________
Place :__________________
Signature of the Proposer
**** Certified that that the contents of the proposal form and documents have been fully explained to the Proposer and that he/they have fully understood the significance of the proposed
contract.
Date ____ / ____/ ____
Name of the Intermediary/Officer of the Company: ___________________________________________________________
Code Number/Employee Number: ___________________________________
Place and Date: _________________________________ Signature of Intermediary/Officer of the Company
****This is required only where, for any reason, the Proposal Form and other connected papers are not filled by the Prospect/Proposer.
INSURANCE ACT 1938 SECTION 41- Prohibition or Rebates
No person shall allow or offer either, directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind or 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 on the policy nor shall any person taking out or renewing or continuing a
policy accept rebate except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer.
Any person making default in complying with the provision of this Section shall be punishable with fine, which may extend to ten lakh rupees.

Bajaj Allianz General Insurance Co. Ltd | G.E. Plaza, Airport Road, Yerawada,Pune - 411006. IRDA Reg No.: 113.
Website: www.bajajallianz.com | Call: 1800-209-0144/1800-209-5858 | CIN: U66010PN2000PLC015329 UIN: IRDAN113P0003V01201718 | E-mail: [email protected]