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New India Insurance

New India Insurance

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Published by lovingboy22

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Published by: lovingboy22 on Dec 23, 2008
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11/07/2012

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HO/MTD/Prop.14.08.2008 Page 1
PROPOSAL FORM FOR TWO WHEELERS/PRIVATE CAR/COMMERCIAL/MISC. & SPL. TYPE OF VEHICLES
PACKAGE POLICY / LIABILITY ONLY POLICY 
1. Insured Details:-
Proposer's (Owner’s) Full Name:Male / FemaleOccupation:Date of BirthNationality:E-Mail Address:PAN No.:Address ( where vehicle is normally kept and used):Address (Permanent)
Period proposed for insurance
From:______AM / PM of _____________ to Mid Night of ___________ 
2.1 - Date of Purchase of Vehicle by Proposer
New/Second Hand Yes/No
2.4 - Is vehicle in good condition?
 Yes/No
Give Vehicle Details2.5 - Type of Vehicle(2 W/Pvt Car /Comm.)2.6 - Current Ownership2.7 - New Vehicle
 Yes/No
2.8 -Year of Manufacture2.9 - Date of Purchase2.12 -Color of Vehicle2.10 - Registration No.2.11 - Date of Registration2.13 - Engine No2.14 - Chassis No2.15 - Make2.16 - Model2.17 - Type Of Body2.18 - Variant2.19 - Vehicle Zone :
A/B/C
2.21 - Whether vehicle is used for driving tuition
 Yes/NoYes/No Yes/NoYes/No Yes/No
2.26 - Fibre Glass Tank Fitted
 Yes/No Yes/No
If Yes then Name of AssociationMembership NoDate of Expiry
 Yes/No
Details of Vehicle Condition2.29 - Is the vehicle fitted with Anti-theft device
 Yes/No
Give, details - Type / Model2.30 - Obsolete Vehicle
 Yes/No
2.31 - Extension of Geographical Area required
 Yes/No
2.32 - Vehicle Invoice Value
Rs.
2.32(i) - Body Building Cost
Rs.
2.33 - Registration validity date2.34 - Vehicle Requisitioned by Government
 Yes/No
2.35 - Insured's Declared Value (IDV)
Rs.
No.of days for Rally2.38 -Seating Capacity2.39 - Cubic Capacity
 Yes/No
If Yes thenNumber of Trailers AttachedTotal IDV of the Trailer Attached
 Yes/No
N.B. * For Office Use OnlyTe queres mae/etas state eow are te mnmum requrements to e urnse y a proposer.The Insurer may seek any otherinformation as desired for underwritin urose.Dev. OfficerName & Code *Agency CodeName * Mobile No.:Fax No:__________________________________________________________________________________________________________________________________________________________________
2. Particulars of the vehicle:
2.3 - Is Vehicle New or Second Hand atthe time of purchase?2.2 - Vehicle Used for Private,Social,domestic,pleasure, professional purpose2.20 - Type of Fuel(Petrol/CNG/LPG/Bi-fuel)2.22 -Vehicle use is limited to ownpremises2.23 - Whether vehicle belongs to foreignembassy or consulate or Imported vehiclewithout Custom Duty2.24 - Whether vehicle is certified asVintage car by Vintage and Classic CarClub of India2.25 - Vehicle designed forBlind/Handicapped/Mentally Challenged personsand endorsed by RTAIf Yes then Value of Fibre glass fuel2.27 - Are you a member of AutomobileAssociation of India2.28 - Car in roadworthy condition and free fromdamageIf yes: Extension to:1. Bangladesh 2.Bhutan 3. Nepal,4 Pakistan 5 Srilanka2.36 - Whether Rally extension required forMotor Racing / Speed Test2.37 - Name and Address of RegistrationAuthorit2.40 - Whether trailer attached to the vehicle
(
For Commercial Vehicle)Is the vehicle proposed for insuranceUnder Hire Purchase / UnderLease Agreement / Under HypothicationAgreement.
I
f Yes, give name and address of concerned parties :
________________________________________________________________________________________
 
 
HO/MTD/Prop.14.08.2008 Page 2
 
 
HO/MTD/Prop.14.08.2008 Page 3
2.41 - Extra Electrical/ Electronic fittings
 Yes/No
If Yes thenValue of Music System
Rs.
Value of AC/Fan
Rs.
Value of Lights
Rs.
Value of Other Fittings
Rs.Rs.
2.42 - Non-Electrical/ Electronic fittings
Rs.
2.43 - Additional Towing Coverage Required
 Yes/NoRs.
2.44 - Value of Side Car
Rs.
Value of CNG/LPG Kit
Rs.
3. DRIVER/ DRIVING LICENCES PARTICULARS :
3.1 - Do You Hold Valid Driving License
 Yes/No
3.2 - Age of Owner Driver3.3 - Owner Driver Driving License No3.4 -Owner Driver License Issue Date3.5 - Owner Driver License Expiry Date3.6 - License Issuing Authority for Owner Driver3.7 - Name of Nominee3.8 - Do you Have Any other Driver
 Yes/No Yes/No
If yes, give details3.9 - NCB Applicable %
4. PREVIOUS INSURANCE PARTICULARS :
4.1 - Name of Previous Insurer4.3 -Previous Policy Number4.2 - Address of the Previous Insurer4.4 - Expiry date of previous Policy4.5 - Voluntary Excess for PC
Rs.
5. PERSONAL ACCIDENT COVERS :
 Yes/No
5.3 - Names of Named person5.4 - Individual CSI for Named Person
Rs.
Capital SI for All Named Persons
Rs.
 Yes/No
If Yes then No of Paid Drivers5.6 - Individual CSI for Paid Driver
Rs.
Capital SI for Drivers
Rs. Yes/No
If Yes then No of unnamed Persons5.8 - Individual CSI for unnamed PersonCapital SI for unnamed Persons
Rs.
5.9 - Nominee particulars :Name, Sex and Age6. LEGAL LIABILITY COVERAGE : (Applicable for Commercial vehicles)
 Yes/No Yes/No Yes/No Yes/No
Total Value of Extra Electrical/Electronic fittingsValue of Non- Electrical/ ElectronicfittingsIf Yes then Additional Towing CoverageAmountIf Yes then License Type of OwnerDriverIn the past three years, whether the driver metwith accident/s and convicted for such offences5.1 - Do you want to include PA cover for NamedPerson5.2 - If Yes then Number of NamedPersons5.5 - Do you wish to include PA Cover for PaidDrivers5.7 -Do you want to include PA cover forunnamed person6.1 - LL to paid drivers,cleaner employed foroperation. and/or maintenence of vehicle underWCAIf Yes then Number of Drivers LegallyLiable6.2 - LL to Employees of Insured traveling and /or driving the VehicleIf Yes then Number of employeesLegally liable.6.3 - LL to Soldiers/Sailors/Airmen employed asDriversIf Yes then Number of LL toSoldiers/Sailors/Airmen6.4 - Do You want to reduce TPPD cover to thestatutory limit of Rs.6000

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