PROPOSAL FORM FOR INSURANCE OF MOTORCYCLE USED FOR PRIVATE/PROFESSIONAL PURPOSES ONLY
Name of Proposer
Business/Occupation
Address
Current Mailing Address:  
Contact Phone
Email Address
Address
Registered no

Chasis no.
 
  
Engine no.    
Make    

Cubic Capacity(cc)		    

Year of manufacture		    

Price paid by proposer 		   

Date of delivery		    

Whether new or second hand at time of delivery
   

Proposer's estimate of Present value including accessories thereon Rs.
   
 
1. Are you owner of Motorcycle and is it registered in your name?

Is there any H/P or charge on Motorcycle: if so give details

2. Will Motorcycle be used of Carrying?

Is Motorcycle in perfect working condition? Please also indicate permit details

 

State, open or locked

3. Address where Motorcycle is usually garaged:
4. Will Motorcycle be driven other than by proposer? If so, give details
5. Have you ever been Insured for Motorcycle Insurance? If so, state name of company.
 
 
6. Has any Company:    
a) Refused to Renew or cancel your Policy?  
b) Declined your proposal for Insurance?  
c) Increased your premium or imposed special conditions on renewal?  
d) Required you to bear first portion of any own damage claim?  
  If so, give details    
 
 
 
7. Period of insurance

 

 From:

To:   

8. Do you propose Comprehensive/Liability to Public Risk Insurance?
9. Will you bear portion of each claim for loss or damage to Motorcycle? If so, state amount Rs.
10. If more than one Motor Cycle insured, give details of all Motor Cycle owned by your Pol. no. & Exp. Date
11. Do you wish to cover Riot and strike Risks, Earthquake
12. Are you entitled to No Claim Discount from your previous Insurers?

If so, please state discount percentage for the same.

 
 
WE HEREBY DECLARE AND WARRANT that above statements are true and complete. I/We desire to efect insurance as described herein with the company and I/We agree that this proposal and declaration shall be basis of contract between me/us and the Company and I/We agree to accept Policy subject to conditions prescribed by the Company.
Place Date
 
 
 
 
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