PROPOSAL FORM FOR INSURANCE OF COMMERCIAL VEHICLE
 
Name of Proposer
Business/Occupation
Address
Current Address:  
Contact Phone
Email Address
Address
Registered no.

Chassis no.
Engine no.

Make		    

Cubic Capacity(cc)		    

Type of body		    

Year of manufacture		    
Licensed carrying capacity good in Tons Passengers in nos.(including driver)    

Price paid by proposer 		Rs.  

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 Vehicle and is it registered in your name?

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

 

 
2. Will Vehicle be used of Carrying?

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

 



3.		 Address where Vehicle is usually garaged:

State, open or locked

4. Will Vehicle be driven other than by proposer? If so, give details
5. Have you ever been Insured for Vehicle Insurance? If so, state name of company.
6. Has any Company:
a) Refused to Renew or cancel your Policy?  
b) Declined your proposal for Insurnce?  
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

 
 
8. Period of insurance From:

To:    

9. Do you propose Comprehensive/Liability to Public Risk Insurance?
10. Will you bear portion of each claim for loss or damage to Vehicle? If so, state amount Rs.
11. If more than one Vehicle insured, give details of all Vehicle owned by your Pol. no. & Exp. Date
12. Do you wish to cover Riot and strike Risks, Earthquake?
13. Are you entitled to No Claim Discount from your previous Insurers?
If so, please state discount percentage for the same.
 
I /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 /We agree to accept Policy subject to conditions prescribed by the Company.
Place Date
 
 
 
 
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