Raheja QBE General Insurance Company Limited

5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai-400059, India.
Contact No: 022 69155050, Toll Free: 1800 102 77 23
Email: [email protected] I Website: www.rahejaqbe.com
CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141 (Category - Non-Life)

PROPOSAL FORM FOR PRIVATE CAR POLICY - BUNDLED

Application Number: _______________________

Note: 1) Policy wording are available on request. 2) Please complete all sections in capitals &
tick boxes wherever applicable. 3) Failure to disclose facts material to assessment of the risk or
providing misleading information shall render the contract void. 4) Geographical Area of
operation: INDIA.

Is the Vehicle Made in India? Yes No

Type of Cover Required: Bundled Policy

For Office Use Only

Policy Number: Date [DD/MM/YYYY]:

Inspection Lead No.

Intermediary Details (To be filled

filled in
in BLOCK
BLOCK CAPITALS)
CAPITALS)

Intermediary Name: Code:

Branch Name: Code:

Sales Manager Name: Code:

Details (To be filled in BLOCK CAPITALS)

1. This proposal is for: Rollover Policy: Used Policy: Renewal:

2a. Proposer’s/Insured Full Name (Registered Owner of the Vehicle):

2b. Address: ______________________________________________________________________________

___________________________________________________________________________________________

2c. Proposer’s/Insured NEFT details:

Full Name of the Account Holder: _______________________

Bank Name: _________________

Account Number: ______________________________________ IFSC Code: ________________________

Private Car Package Policy- IRDAN141RP0016V01201920

 Raheja QBE General Insurance Company Limited
5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai-400059, India.
Contact No: 022 69155050, Toll Free: 1800 102 77 23
Email: [email protected] I Website: www.rahejaqbe.com
CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141 (Category - Non-Life)

Address at which the vehicle

Address of Communication
is registered
Flat/Building/Door/Block No
Road/Street/Sector
Nearest Landmark
Area
City
Pin Code
State
Country

City where vehicle is primarily used: ________________________

Phone Number: ________________________ Mobile No.: _______________________

Email: ________________________ Fax: _______________________

3. Occupation of the Insured: _________________________ (Salaried/ Self Employed/ Profession)

4. Period of Insurance:

Section I (Own Damage) - From: ___ /___ Hours of DD/MM/YYYY to: Midnight of DD/MM/YYYY

Section II (Third Party) - From: ___ /___ Hours of DD/MM/YYYY to: Midnight of DD/MM/YYYY

(Note: Cover will commence not earlier than the date & time of acceptance of risk and
subsequent to the payment of premium by the insured to the company and realization thereof
by the Company.)

5. Source of Fund:
Business: __________________ Profession: ________________ Salary: ____________________
Agricultural Income: ________ Savings: ___________________ Others: ___________________

6. Monthly Income:
Up to ₹ 20,000 ₹ 20,001- ₹ 50,000
₹ 50,000 - ₹ 1,00,000 ₹ 1,00,000 and above

7. Do you have a GST registration number: Yes No

If yes, please specify __________________________________________

8. Related Party: Yes No

Private Car Package Policy- IRDAN141RP0016V01201920

Raheja QBE General Insurance Company Limited
5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai-400059, India.
Contact No: 022 69155050, Toll Free: 1800 102 77 23
Email: [email protected] I Website: www.rahejaqbe.com
CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141 (Category - Non-Life)

Additional KYC details*

CKYC number (Mandatory for KYC update

request)

Identity Proof
A- Passport number
B- Aadhar card
C- PAN card
D- Driving License
E- Voter ID card
Z- Others (any Document
notified by the central
government)

Proof of address (tick any one)

Passport Please specify document name and details if
Driving license Others:
Voter ID card
Electricity or Telephone
Bill
Others

Insurance Account (eIA)*

If you already have an eIA, provide details:
a) Name of Insurance Repository
b) eIA No:
c) Name as appearing in eIA

If you do not have an eIA, would you like to Yes No

open an account?
 CAMS Repository Services Limited
If Yes, choose any one Insurance Repository:
 NSDL Data Management Limited
 Karvy Insurance Repository Limited
 Central Insurance Repository Limited

Private Car Package Policy- IRDAN141RP0016V01201920

 Raheja QBE General Insurance Company Limited
5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai-400059, India.
Contact No: 022 69155050, Toll Free: 1800 102 77 23
Email: [email protected] I Website: www.rahejaqbe.com
CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141 (Category - Non-Life)

Details of the Vehicle

9. Registration 10. Date of

Number: Registration:
11. Registering 12. Year & Month of
Authority & Location: Manufacture:
13. Engine Number 14. Chassis Number:
16. Model of the
15. Make of Vehicle:
vehicle:
17. Is the vehicle
18. Type of Body:
Imported? Yes/ No
20.Seating capacity
19. Cubic Capacity:
including Driver:
21. Fuel Type: Petrol/
Diesel/ Others

Details of the Vehicle – Type and Use

22. Whether the Vehicle is driven by Non-conventional

Yes No
source of power?
If yes Bi Fuel CNG LPG

Important: Insured’s Declared Value (IDV) Age of the Vehicle Depreciation

The Insured’s Declared Value (IDV) of the vehicle will be deemed Not exceeding 6
5%
to be the ‘SUM INSURED’ for the purpose of this tariff and it will be Months
fixed at the commencement of each policy period for each insured
vehicle. Exceeding 6 months
but not exceeding 1 15%
The IDV of the vehicle is to be fixed on the basis of the
year
manufacturer’s listed selling price of the brand and model as the
vehicle proposed for insurance at the commencement of
insurance/renewal and adjusted for depreciation (as per schedule Exceeding 1 year but
20%
alongside). The IDV of the side car(s) and/ or accessories, if any, not exceeding 2 years
fitted to the vehicle but not included in the manufacture’s listed
selling price of the vehicle is/ are also likewise to be fixed.

The schedule of age-wise depreciation as shown alongside is Exceeding 2 years but

30%
applicable for the purpose of Total Loss/Constructive Total Loss not exceeding 3 years
(TL/CTL) claims only. The vehicle will be considered to be a CTL
where the aggregate cost of retrieval and/or repair of the vehicle
subject to terms & conditions of the policy exceeds 75% of the IDV. Exceeding 3 years but
40%
not exceeding 4 years
IDV of obsolete models of the vehicles (i.e. models which the
manufacturers have discontinued to manufacture) and vehicles
beyond 5 years of age will be determined on the basis of Exceeding 4 years but
50%
understanding between the Insurer and Insured. not exceeding 5 years

Private Car Package Policy- IRDAN141RP0016V01201920

 Raheja QBE General Insurance Company Limited
5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai-400059, India.
Contact No: 022 69155050, Toll Free: 1800 102 77 23
Email: [email protected] I Website: www.rahejaqbe.com
CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141 (Category - Non-Life)

Insured Non-Electrical Electrical and Side Car Value of Total

Declared Accessories Electronic (Two- CNG/ LPG Kit Value
Value (IDV) of fitted to the Accessories Wheeler)
the Vehicle Vehicle fitted to the
Vehicle

23. Age of Owner Driver & Date of Birth: _______ years, DD/MM/YYYY.

24. Add On Covers (subject to availability & eligibility)

a. Zero Depreciation Yes No
No of Claims Opted for_______
b. Return to Invoice: Yes No
Road Tax amount paid: INR_______
Registration Charges Paid: INR_________
Do you have invoice of vehicle: Yes No
Invoice Value of vehicle: INR______________
c. Consumable Expenses: Yes No
d. Daily Conveyance Benefit Yes No
Per day allowance______________ Coverage Days_____________
Franchise Days_________________ No. of Claims Opted for_____
e. Engine Protector Yes No
f. Tire & Rim Protector Yes No
Specifications of Tire & Tubes _________________________________
g. Key Protect Cover Yes No
h. Loss of Personal Belongings Yes No
Benefit Amount:___________
i. NCB Retention Cover Yes No
j. Road Side Assistance Yes No
k. Road Side Assistance Gold Yes No
l. Pay As you Drive No. of KMs Opted for: ______ Yes No

25. Is the Vehicle fitted with any Anti-theft device approved by the Yes No
ARAI?

If yes, please attach certificate of Installation in the vehicle, issued by Automobile Association
of India.

Private Car Package Policy- IRDAN141RP0016V01201920

 Raheja QBE General Insurance Company Limited
5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai-400059, India.
Contact No: 022 69155050, Toll Free: 1800 102 77 23
Email: [email protected] I Website: www.rahejaqbe.com
CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141 (Category - Non-Life)

26. Are you a member of Automobile Association of India? Yes No

If yes, please submit membership copy.
a. Name of the Association: _______________________________
b. Membership Number: __________________________________
c. Date of Expiry: DD/MM/YYYY

27. Will the Vehicle be exclusively used for?

a. Private, social, domestic, pleasure and professional purposes? Yes No
If no, then state the purpose of actual use _________________________________
b. Carriage of goods other than samples or personal luggage or
Yes No
commercial purpose?

28. Whether the Vehicle is used for Driving Tuitions? Yes No

29. Whether the Vehicle is limited to Own Premises? (Only if not Yes No
licensed for general road use by RTO)
Yes No
30. Whether the Vehicle is fitted with Fibre Glass Tank?

31. Whether the Vehicle belongs to the Embassy/Consulate of a Yes No

foreign country?
If so, is the duty element included in the IDV? Yes No

32. Whether the Vehicle is designed for use of Blind/ Handicapped/

Yes No
Mentally Challenged Person? (Attach RC Copy)

33. Date of purchase of Vehicle by the Proposer: DD/MM/YYYY

34. Whether the Vehicle at the time of purchase was New Second Hand

35. Is there a valid PUC certificate for the said vehicle? Yes No
If Yes, please provide expiry date of PUC: DD/MM/YYYY
(Please not insurance cannot be granted if insured does not have valid PUC at the date of
commencement of policy)

36. Whether the vehicle is used for commercial purpose? Yes No

Risk Inclusions

37. Please select the higher deductible if you wish to opt for over and above the compulsory
deductible (₹.1,000 for vehicles not exceeding 1500 CC, ₹.2,000 for vehicle exceeding 1500 CC)

Private Car: ₹. 2,500 ₹. 5000 ₹. 7500 ₹. 15000

Private Car Package Policy- IRDAN141RP0016V01201920

 Raheja QBE General Insurance Company Limited
5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai-400059, India.
Contact No: 022 69155050, Toll Free: 1800 102 77 23
Email: [email protected] I Website: www.rahejaqbe.com
CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141 (Category - Non-Life)

38. Liability to third parties: The policy provides Third Party Property Damage (TPPD) of ₹. 7.5
lakh (Private Car)
Do you wish to restrict the above limits to statutory TPPD Liability
Yes No
limit of ₹. 6000/- only?

39. Do you wish to cover Legal Liability to?

a. Driver (No. of Persons____) Yes No
b. Other employees (No. of Persons____) Yes No
c. Unnamed Passengers (No of Persons______) Yes No

40. Do you wish to include Personal Accident (PA) cover for named
Yes No
persons?
If yes, give name and Capital Sum Insured opted for. The maximum CSI available per person is
₹. 2 Lacs
CSI Name of Age of % of Name of
Name Relationship Address
Opted Nominee Nominee Nominee Appointee

a. Bank account details of the nominee

1st Nominee 2nd Nominee 3rd Nominee 4th Nominee

Account no.:
Account Type-
Savings/Current:
Name of the Bank
& Branch:
MICR code( 9 digit)
IFSC code( 11
character code):
Note: In case of more than 1 nominee, please attach a separate annexure mentioning all the
detail of the nominees with their share in %:

41. Do you wish to include PA cover for Unnamed persons/ hirer? Yes No
If yes, give name and Capital Sum Insured opted for. The maximum CSI available per person is
₹. 2 Lacs
Number of Persons CSI Opted

42. Personal Accident cover for Owner-Driver. Please give details of nomination.
Name Name of Age of Name of Relationship Address
Nominee Nominee Appointee

Private Car Package Policy- IRDAN141RP0016V01201920

 Raheja QBE General Insurance Company Limited
5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai-400059, India.
Contact No: 022 69155050, Toll Free: 1800 102 77 23
Email: [email protected] I Website: www.rahejaqbe.com
CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141 (Category - Non-Life)

Note: 1. Personal Accident cover for owner driver is compulsory for Sum Insured of ₹.1500000/-
for Private Car.
2. Compulsory PA cover for owner driver cannot be granted where a vehicle is owned by a
company, a partnership firm or a similar body corporate or where the owner-driver does not hold
an effective driving license
3. Since a General Personal Accident Policy cover against motor accidents, if an owner driver
already has a 24 hours Personal Accident cover against Death and Permanent Disability (Total
& Partial) for CSI of at least ₹.15 Lacs, there is no need for a separate PA cover to be taken.

43. Extension of Geographical Area:

Whether extension of Geographical Area to the following countries required?

Bangladesh Bhutan Maldives Nepal SriLanka Pakistan

44. Please state if the vehicle Hire Lease Hypothecation

is under: purchase Agreement Agreement
If so, give name and address of concerned parties.

45. Full Name:

46. Address:

47. Any other material facts relevant for this insurance?

____________________________________________________________________________________________

(Note: Copies of R.C. & Fitness Certificate should be submitted along with the proposal form)

48. Do you need physical copy of the policy? Yes No

Payment Details

Cheque/DD Cheque/DD Number:

Cheque Date: DD/MM/YYY Cash: Credit Card: Others:

49. Bank Details of the Customer:

Full Name of the Account Holder: _____________________________ Bank Name: ________________

Account Number: ____________________________________________ IFSC Code: _________________

Details of Previous Insurance

50. Add On Opted? Yes No

if yes please name the add on covers__________________________

51. NO CLAIM BONUS (NCB) allowed under previous policy (%):

Private Car Package Policy- IRDAN141RP0016V01201920

 Raheja QBE General Insurance Company Limited
5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai-400059, India.
Contact No: 022 69155050, Toll Free: 1800 102 77 23
Email: [email protected] I Website: www.rahejaqbe.com
CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141 (Category - Non-Life)

52. Claim lodged during the preceding 3 years: Yes No

If Yes: Year Number Claim Amount

53. Are you entitled to No Claim Bonus: Yes No

If yes, please submit / attached proof thereof

Required an increase in
54. Has any Declined Your Proposal
premium
insurance company
Cancelled or Refused Imposed Special
ever?
your Renewal Conditions or Excess

I/We hereby declare that the rate of NCB claimed by me/ us is correct and that No claim has
arisen in the expiring policy period (copy of policy enclosed). I/ We undertake that if this
declaration id found incorrect, all benefits under this policy in respect of Section 1 of the policy
will stand forfeited.

Signature of the Proposer

55. Details of Drivers:

a) Age - Owner Driver: DD/MM/YYYY Other: DD/MM/YYY

b) Does the driver suffer from defective vision or hearing or any

Yes No
physical infirmity?
if “Yes” Please give details __________________________________________________

c) Has the driver ever been involved/convicted for causing any

Yes No
accident or loss?
If yes, please give details as under including the pending prosecution if any.

Circumstances of
Driver’s Name Date of Accident Loss/ Cost ₹.
Accident/ Claim

d) Driving Experience _____________________________

Private Car Package Policy- IRDAN141RP0016V01201920

 Raheja QBE General Insurance Company Limited
5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai-400059, India.
Contact No: 022 69155050, Toll Free: 1800 102 77 23
Email: [email protected] I Website: www.rahejaqbe.com
CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141 (Category - Non-Life)

AML Guidelines

Are you or any of the proposed applicants/beneficial owner a PEP*

Yes No
or a close relative of a PEP*?
If yes, please provide details: ________________________________

* Politically Exposed Persons (PEPs) are individuals who are or have been entrusted with
prominent public functions in a foreign country, e.g., Heads of States/ Governments, senior
politicians, senior government/judicial/military officers, senior executives of state-owned
corporations, important political party officials, etc.
I/ We hereby confirm that all premiums have been/ will be paid from bonafide sources and no
premium has been/ will be paid out of the proceeds of crime related to any of the offence listed
in Prevention of Money Laundering Act 2002. I understand that the company has the right to call
for the documents to establish source of funds. The insurance company has the right to cancel
the insurance contract in case I am/ have been found guilty by any competent court of law under
any of the statues, directly/ indirectly governing the Prevention of Money Laundering in India.

Non- If, Non-Indian please specify the country

Nationality: Indian
Indian ____________________

Type of Organization:

Corporations Government NGO Society Trust

International Section 8
Partnership Cooperatives
Organization companies

Declaration

I/We hereby give my/our consent to Raheja QBE General Insurance Company Limited (‘the
Company’) to verify and obtain my/our identity/address proof as well as the identity /address
proof of the insured through Central KYC Registry or UIDAI or through any other modes for the
purpose of undertaking KYC.

I/We hereby declare that the statements, answers & particulars made by me/us in this Proposal
Form are correct, complete & true to the best of my/our knowledge and belief and I/We hereby
agree that this declaration shall form the basis of the contract between me/us and Raheja QBE
General Insurance Company Limited. It is hereby understood that the statements, answers and
particulars provided herein above, are the basis on which this insurance is being granted and
that if, after the insurance is effected, it is found that any of the statements, answers or
particulars are incorrect or untrue in any respect, the company shall have no liability under this
insurance.

Private Car Package Policy- IRDAN141RP0016V01201920

 Raheja QBE General Insurance Company Limited
5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai-400059, India.
Contact No: 022 69155050, Toll Free: 1800 102 77 23
Email: [email protected] I Website: www.rahejaqbe.com
CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141 (Category - Non-Life)

I/We also declare that, if any additions or alterations are carried out after the submission of this
proposal form, would be conveyed to the Insurance Company immediately and in such event it
shall be at the discretion of the Company as to whether to continue and/or modify/alter with
additional terms and conditions with the cover as may be granted. I/ We hereby states that the
above mentioned address shall be taken as address on record for the purpose of GST.
This proposal form was completed by
Name: _______________________________ Place: _______________________________

Date: _______________________________

Declaration when the proposal form is filled by a person other than the proposer/ the proposer
signs in a vernacular language/ proposer is illiterate

I hereby declare that I have read out and explained the content of this proposal form and all other
connected documents incidental to availing the insurance policy from Raheja QBE General
Insurance Company Ltd. to the proposer and that he/ she confirmed that he/ she has understood
the same and that he/ she agrees to abide by all the terms & conditions of the same.

I hereby declare that I have fully explained to the proposer the answers to the questions that
form the basis of the contract of insurance have also explained the contents in this form to the
proposer in ________ language, that I have truly and correctly recorded the answers given by the
proposer and that the proposer has affixed his/ her thumb impression on the proposal form in
my presence, after fully understanding the contents thereof. Further, this declaration does not
confirm issuance of policy or assumption of risk thereof.

Name of the Witness

Name of the Proposer
Signature of Witness
Date [DD/MM/YYYY]
Place
Address of Witness
Relationship with Proposer

Signature of the Proposer/Insured

Private Car Package Policy- IRDAN141RP0016V01201920

 Raheja QBE General Insurance Company Limited
5th Floor, A Wing, Fulcrum, IA Project Road, Sahar, Andheri East, Mumbai-400059, India.
Contact No: 022 69155050, Toll Free: 1800 102 77 23
Email: [email protected] I Website: www.rahejaqbe.com
CIN: U66030MH2007PLC173129, IRDAI Registration Number: 141 (Category - Non-Life)

Prohibition of rebates - Section 41 of The Insurance Act 1938

1. No person shall allow or offer to allow, either directly or indirectly, as an inducement to any
person to take out or renew or continue an insurance in respect of any kind or risk relating to
lives or property in India, any rebate of the whole or part of the commission payable or any rebate
of the
premium shown on the policy, nor shall any person taking out or renewing or continuing a policy
accept any rebate, except such rebate as may be allowed in accordance with the published
prospectuses or tables of the insurer.

2. Any person making default in complying with the provisions of this Section shall be punishable
with fine which may extend to Rs. 10 Lacs

INSURANCE IS THE SUBJECT MATTER OF SOLICITATION

Private Car Package Policy- IRDAN141RP0016V01201920