PROPOSAL FORM FOR TWO WHEELER/PRIVATE CAR/COMMERCIAL VEHICLE LIABILITY POLICY

(The queries made/details stated below are the minimum requirements to be furnished by a proposer.The Insurer may seek any other information as desired for underwriting purpose)

Coverage required for: PRIVATE CAR TWO WHEELER COMMERCIAL VEHICLE

Dev. Officer Name & Code Agency/Intermediary Code &

1. Insured Details:-
(Office Use Only) Name (Office Use Only)
Gender: Male / Female /
Proposer's (Owner’s) Full Name: M F OTH Occupation:
Others
Tel. No :
_________________________________________________________________________________________ Nationality:
Mobile No.
Date of Birth: CKYC No. Aadhar No.
Email ID: PAN No.: Driving Licence No.
Bank Account No.: Name of the Bank: Passport No.
IFSC Code: Address of the Bank Voter ID Card No.
GSTIN No.
Address ( where vehicle is normally kept and used) Address (Permanent)

_____________________________________Pin_____________________________ _____________________________________Pin_____________________________
2. Nominee's Details:
Nominee's Full Name: Gender:
Date of Birth:
____________________________________________________________________________________ Male / Female / Others
Tel. No :
Relationship with Insured: Nationality:
Mobile No.:
Bank Account No.: Occupation: E-Mail Address:
Corresponance Address : Address (Permanent) :

_________________________________________________________________________ _____________________________________________________________________

____________________ Pin_________________________________________________ ____________________ Pin_____________________________________________

3. In Case Nominee is a Minor:
Name of Guardian: Address of Guardian:
_______________________________________________________________________

Mobile No.: _______________________________________ ___________________________________________________________________

Pin______________

4. Other Insurance Details:

If Yes,
YES NO Insurer Name: _______________________________________________________________________________________
Whether Vehicle is already Insured with other Insurer
Policy No.: _________________________________Period of Insurance____________________________________

5. Period proposed for insurance From:_________________AM / PM of _________________________________ to Mid Night of _______________________________

6. Particulars of the vehicle:

Registration No. Class of vehicle
Chassis No Engine No
Make Model & Variant
Cubic Capacity in CC/KW Type of Fuel - Petrol/CNG/LPG/Bi-fuel / Electric Vehicle
Year of Manufacture Gross Vehicle Weight
Name and Address of Registration Authority Date of Registration
Registration validity date Seating Capacity of the Vehicle
Color of Vehicle
7. Additional Details of the vehicle:
Is Vehicle New or Second Hand at the time of purchase? NEW SECOND HAND Current Ownership
Vehicle Used for Private, Social, domestic, pleasure, professional purpose YES NO Is vehicle in good condition? YES NO
Date of Purchase of vehicle Obsolete Vehicle YES NO
Whether vehicle is used for driving tuition YES NO Vehicle use is limited to own premises YES NO
Whether vehicle belongs to foreign embassy or consulate or Imported vehicle YES NO Whether vehicle is certified as Vintage car by Vintage and Classic Car YES NO
without Custom Duty Club of India
Vehicle designed for Blind/Handicapped/Mentally Challenged persons and YES NO
endorsed by RTA
Car in roadworthy condition and free from damage YES NO Details of Vehicle Condition
YES NO If yes: Extension to: 1. Bangladesh 2. Bhutan 3. Nepal,4 Pakistan
Extension of Geographical Area required
5. Srilanka 6. Maldives
Vehicle Requisitioned by Government YES NO
Whether Rally extension required for Motor Racing / Speed Test YES NO No.of days for Rally
YES NO If Yes then,Number of Trailers Attached:_________
Whether trailer attached to the vehicle (For Commercial Vehicle)

Is the vehicle proposed for insurance is Under Hire Purchase / Under Lease YES If Yes, give name and address of concerned parties :
NO
Agreement / Under Hypothication Agreement. _________________________________________________

If Side Car is attached YES NO

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 NO
8. COMPULSORY OWNER DRIVER PA
Do You Hold Valid Driving License YES NO If Yes then License Type of Owner Driver
(If No'please refer declaration on page 3)*
Age of Owner Driver Owner Driver Driving License No
Owner Driver License Issue Date Owner Driver License Expiry Date
License Issuing Authority for Owner Driver Name of Nominee:
Do you have any other PA/CPA Policy with Minimum SI Rs. 15 Lac YES NO If Yes, Please provide Details

9. DRIVER/ DRIVING LICENCES PARTICULARS :

Do you Have Any other Driver YES NO
In the past three years, whether the driver met with accident/s and convicted for YES NO If yes, give details:
such offences
10. PREVIOUS INSURANCE PARTICULARS :
Name of Previous Insurer Previous Policy Number
Address of the Previous Insurer Expiry date of previous Policy
Voluntary Excess Rs. No. of Claims (if any)
NCB Applicable %

11. PERSONAL ACCIDENT COVERS :

Do you want to include PA cover for Named Person YES NO If Yes then Number of Named Persons

Names of Named person Mr/Ms/M/s

Individual CSI for Named Person Rs. Capital SI for All Named Persons Rs.
Do you wish to include PA Cover for Paid Drivers YES NO If Yes then No of Paid Drivers
Individual CSI for Paid Driver Rs. Capital SI for Drivers Rs.
Do you want to include PA cover for unnamed person YES NO If Yes then No of unnamed Persons
Individual CSI for unnamed Person Capital SI for unnamed Persons Rs.
Nominee particulars : Name, Sex and Age

12. LEGAL LIABILITY COVERAGE : (Applicable for Commercial vehicles)

LL to paid drivers,cleaner employed for operation. and/or maintenence of vehicle YES NO If Yes then Number of Drivers Legally Liable
under WCA
LL to Employees of Insured traveling and / or driving the Vehicle YES NO If Yes then Number of employees Legally liable
LL to Soldiers/Sailors/Airmen employed as Drivers YES NO If Yes then Number of LL to Soldiers/Sailors/Airmen
Do You want to reduce TPPD cover to the statutory limit of Rs.6000 YES NO

Declaration by the Proposer

I / We hereby declare that the statements made by me / us in this Proposal Form, including document(s) attached, are true and correct, to the best of my / our knowledge and belief and nothing materially
affecting the risk has / have been concealed by me / us. I / We hereby agree that this declaration shall form the basis of the contract between me / us and "The New India Assurance Co. Ltd." and shall form part
of the insurance contract.
I/We further declare that I/We do not hold an effective Driving License to drive the insured vehicle and therefore I/We am/are ineligible for Compulsory Owner Driver Personal Accident cover. (Please refer point
8 of proposal form)*
I / We further declare that any addition(s) or alteration(s) or modification(s) is / are carried out in the vehicle or in the document(s), during the currency of the policy, furnished / forming part of this Proposal
Form, shall be intimated in writing to the Insurer immediately, failing which, the same shall be construed as breach of the Contract and my / our rights shall be forfeited thereunder, irrespective of whether or
not, the same is material to the losses / Liabilities.
I / We also declare that I / we shall comply with the requirements of M. V. Act, 1988, and subsequent amendments thereto from time to time and rules made there under.
I / We also declare that I / we shall inform this insurer, in case, the Government requisitions this vehicle during the currency of the Policy (GR-38 of IMT).
I/We hereby declare that the vehickle proposed for insurance has a valid PUC & Fitness Certificate(in case of transport vehicles) on the date of fresh issuance/renewal of the policy
I / We also declare that this vehicle shall be handed over to the Driver only after due verification of genuinity and effectiveness of his Driving Licence to drive this vehicle
I / We hereby also declare that I / we am / are willing to accept a policy of insurance in this company’s usual Form.
I/We hereby declare that there is no other Package/Liaibility insurance policy is in existence of the vehicle porposed for insurance.
I Want to avail Policy in Physical Form.

I Want to get the Policy related inforamtion in soft copy.

Place LTI / Signature(s) of the Proposer

Date & Time Name of the Witness with signatue

N. B.: I / We am / are putting my / our signature(s) after understanding the above contents, incorporated in this Proposal Form , read over to me / us, are true and in accordance with my / our version

INSURANCE ACT 1938, SECTION 41 - PROHIBITION OF REBATES

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 prospectus 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 up to Ten Lac Rupees.

CIN Number: L66000MH1919GOI000526 | IRDAI Registration Number: 190

Registered Office Address: The New India Assurance Co. Ltd., #87, M.G.Road, Fort, Mumbai 400 001.
Website: newindia.co.in Toll Free No. 1800-209-1415

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