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PROPOSAL FORM FOR PERSONAL ACCIDENT INSURANCE |
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| 3. |
Does Insured Person(s) duties involve: |
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(a) |
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(b) |
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Other than above, if any |
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| 4.. |
Has Insured person(s) suffered from: |
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| a. |
Physical defect/infirmity. |
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| b. |
Complaint relating to eye sight, hearing, chronic disease, arthritis, diabetes, fit, gout, paralysis. |
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| 5. |
(a) |
Is Insured person(s) at present or had he been Insured for Personal Accident Risks? |
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(b) |
Has Insured Person(s) ever sustained disabledment from accident? |
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(c) |
Has Insured Person(s) made any claim under Personal Accident Policy? |
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(d) |
Has any company declined proposal, or cancelled Insurance or required special terms or refused renewal thereof? |
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| 6. |
State any other information material to this Risk. |
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| 7. |
(a) |
Capital Sum Insured required Rs. |
Nrs. |
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(b) |
Benefits required:
Click Insurance Cover for details |
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WE HEREBY DECLARE AND WARRANT that above statements are true and complete. We shall be basis of Contract between us and the Company and we agree to accept Policy subject to conditions prescribed by the Company.
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