UNITED INDIA INSURANCE COMPANY LIMITED

MOTOR INSURANCE PROPOSAL FORM PRIVATE CAR / TWO WHEELER - PACKAGE

POLICY

MOU / Development Offi e! " De#le! / $!o%e! /A&ent N#me ' Co(e"

P!opo)e!*) N#me A((!e)) fo! Co!!e)pon(en e Telep+one ' F#, N-m.e! E-m#il A((!e)) $#n% A o-nt No/ 0S$/ C-!!ent A o-nt1 HPA/H2pot+e #tion T2pe of Poli 2 Re3-i!e( Pe!io( of In)-!#n e Re&n/No/ En&/No/' C+#)/ No/ Mo.ile No" PAN No"

Package policy
F!om Time44 D#te " Det#il) of Ve+i le 5e#! of M#%e' M#%e Mo(el / T2pe of $o(2 To
C-.i C#p# it2 Se#tin& C#p# it2
Colo-!

F-el U)e(

Re&i)te!in& A-t+o!it2 - N#me #n( lo #tion " V#l-e of t+e Ve+i le" Invoi e Ele t!i / NonSi(e V#l-e Ele t!oni Ele t!i #l C#!/T!#ile! A e))o!ie) A e))o!ie ) LP6/CN 6 7it Tot#l V#l-e IDV

Hi)to!2 of t+e Ve+i le P!evio-) T2pe of Poli 2 ove! No

N#me of In)-!e! ' A((!e))

Entitlement of No Cl#im $on-)

D#te of Poli 2 E,pi!2

Cl#im E,pe!ien e fo! l#)t 8 2e#!)

D#te of fi!)t P-! +#)e ' Re&n/

U)#&e of t+e Ve+i le" Det#il) of P-!po)e of U)e Ve+i le P#!%in& Ple#)-!e Cove!e( 6#!#&e P!ofe))ion#l Un ove!e( 6#!#&e

Det#il) of D!ive! Self P#i( D!ive!

Ave!#&e %m !-n in # 2e#!

$-)ine))/T!#(e Co!po!#te

Wit+in t+e Compo-n( Rel#tive) Ro#()i(e F!ien()

Discoun s ! Loa"ing# Vol-nt#!2 E, e))" Do 2o- 9i)+ to Opt fo! Vol-nt#!2 E, e)) ove! #n( #.ove t+e Comp-l)o!2 Poli 2 E, e)) A!e 2o- # mem.e! of A-tomo.ile A))o i#tion of In(i# I) t+e ve+i le fitte( 9it+ t+e #n2 AntiT+eft Devi e #pp!ove( .2 ARAI W+et+e! t+e ve+i le i) (!iven .2 non- onvention#l )o-! e W+et+e! t+e ve+i le i) (!iven .2 $i--f-el %it / Fi.!e 6l#)) T#n% Fitte( Do 2o- 9i)+ to !e)t!i t TPPD ove! to St#t-to!2 limit of R)/A===/-onl2 A((ition#l ove!) !e3-i!e( T+eft of A e))o!ie) 0T9o 9+eele!) onl21 Le&#l Li#.ilit2 to D!ive! PA fo! p#i( (!ive!
Compulsory Personal Accident Cover for Owner Driver Personal Accident Cover for Owner Driver is compulsory. Please give details of nomination : (a) Name of the Nominee (!) "elationship (c) Name of the Appointee (#f Nominee is a $inor) (d) "elationship to the Nominee Age : : : :

5e)/No : If 2e); ple#)e )pe if2 t+e #mo-nt T9o W+eele! : R)/<==/>==/?===/?<==/8=== P!iv#te 5e)/No If 2e); ple#)e St#te" ?/ N#me of A))o i#tion @/ Mem.e!)+ip No" D#te of E,pi!2 " 5e)/No If 2e); #tt# + e!tifi #te of in)t#ll#tion i))-e( .2 AASI 5e)/No If 2e); ple#)e )pe if2 t+e (et#il)

5e)/No If 2e); ple#)e )pe if2 t+e (et#il)

5e) / No

(Note: %. Personal Accident cover for Owner Driver is compulsory for &um #nsured of "s.%'(('((()* for +wo ,heelers and "s.-'(('((()* for Private Cars. -. Compulsory PA cover to owner driver cannot !e granted where a vehicle is owned !y a
company' a partnership firm or a similar !ody corporate or where the owner*driver does not hold an effective driving license)

P A Cove! fo! N#me( Pe!)on)

Named OccupantsPA Cover for

Do you wish to include Personal Accident cover for named persons/ 01& ) NO' #f 01&' give name and Capital &um #nsured (C&#) opted for: Name C&# Opted Nominee "elationship ("s.) %) -) 2) (Note: +he ma3imum C&# availa!le per person is "s.- 4a5hs in case of Private Cars and "s.% 4a5h in the case of $otori6ed +wo ,heelers)

P A ove! fo! -nn#me( Pe!)on)/Pillion / -nn#me( p#))en&e!)

(#$+*%.)

A(( on Cove!
Nil Dep!e i#tion Co-!te)2 C#! Me(i #l E,pen)e) Pe!)on#l Effe t) Ot+e! Det#il) W+et+e! -)e of ve+i le i) limite( to o9n p!emi)e) W+et+e! t+e ve+i le .elon&) to fo!ei&n em.#))2 W+et+e! t+e C#! i) e!tifie( #) Vint#&e C#! W+et+e! t+e ve+i le i) (e)i&ne( fo! -)e of .lin(/+#n(i #ppe( pe!)on) W+et+e! t+e ve+i le i) -)e( fo! D!ivin& T-ition) W+et+e! e,ten)ion of 6eo&!#p+i #l A!e# i) !e3-i!e( Do 2o- 9i)+ to +#ve # One P#&e Poli 2B .e vie9e( #t o-! 9e.)ite " 999/-ii / o/in$ 5e)/No 5e)/No 5e)/No 5e)/No If 2e); ple#)e )pe if2 t+e (et#il) of En(o!)ement .2 RTA 5e)/No
Nep#l $#n&#l#(e)+;$+-t#n;M#l(ive); P#%i)t#n;S!iL#n%#

5e) / No 0Poli 2 te!m) #n( on(ition) #n

DECLARATION %Y T&E INSURED

I/We +e!e.2 (e l#!e t+#t t+e St#tement) m#(e .2 me/-) in t+i) P!opo)#l Fo!m #!e t!-e to t+e .e)t of m2/o-! %no9le(&e #n( .elief #n( I/We +e!e.2 #&!ee t+#t +i) (e l#!#tion )+#ll fo!m t+e .#)i) of t+e ont!# t .et9een me/-) #n( t+e UNITED INDIA INSURANCE CO/ LTD/ I/We #l)o +e!e.2 (e l#!e t+#t #n2 #((ition) o! #lte!#tion) #!!ie( o-t #fte! t+e )-.mi))ion of t+i) P!opo)#l Fo!m t+en t+e )#me 9o-l( .e onve2e( to t+e In)-!e!) imme(i#tel2/ I/9e 9i)+ to onfi!m t+#t t+e!e +#) .een no # i(ent to m2/o-! ve+i le )in e t+e l#)t Poli 2 E,pi!2 D#te till no9/ I/We onfi!m t+#t I/We +#ve !emitte( t+e p!emi-m #t44444444444 on4444444/

Fo! t+e in)-!#n e of t+e #.ove ve+i le 9it+ 2o-/ It i) -n(e!)too( #n( #&!ee( t+#t 2o- +#ve no li#.ilit2 o! 9+#t)oeve! n#t-!e fo! #n2 Lo))/D#m#&e/Li#.ilit2 #!i)in& o-t of #n2 # i(ent e#!lie! to 44444// 0time1/ I/We (e l#!e t+#t t+e ve+i le i) in pe!fe t )t#te #n( !o#(9o!t+2 on(ition//

Pl# e " D#te "

SI6NATURE OF THE PROPOSER