PROPOSAL FORM FOR INSURANCE OF CARS USED FOR PRIVATE/PROFESSIONAL
PURPOSES ONLY

 
Name of Proposer
Business/Occupation
Address
Current Address:  
Contact Phone
Email Address
Address
Registered no.
Chasis no.
.
  
Engine no    
Make    
Cubic Capacity(cc)    
Type of body    
Year of manufacture    
Passenger Carrying capacity (including driver)
   
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 car and is it registered in your name?

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

 
2. Will car be used of Carrying?

Is car in perfect working condition? Please also indicate permit details.

State, open or locked

3. Address where car is usually garaged:
4. Electrical/Electronic extra equipment if any be specified with value Rs.
5. Have you ever been Insured for car risk before? 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 Car? If so, state amount Rs.
10. If more than one car insured, give no of cars owned by you.
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
 
 
 
 
Site designed and maintained by: INFOCOM Pvt. Ltd.