CBD BELAPUR

RAHUL KOTHARI
46000372
INDIVIDUAL PERSONAL ACCIDENT INSURANCE PROPOSAL FORM
1. Named of the Proposer:..
2. Residential Address/Permanent Address:
3. Address for Correspondence:
4. (a) Profession !cc"pation# $rade or %"siness:
(Please descri&e f"ll' (ith nat"re of d"ties)
(&) Are 'o" primaril' en)a)ed in administrati*e
f"nction. +es/No
(c) ,oes 'o"r occ"pation re-"ires 'o" to en)a)e
in man"al la&o"r. +es/No
(d) ,o 'o" en)a)e in
i) Racin) on (heels or .orse&ac/
ii) %i) )ame h"ntin)
iii) 0o"ntaineerin)
i*) 1inter sports# s/iin) or ice hoc/e'
*) %alloonin) or polo or 2ports of similar nat"re
(e) 1hat is 'o"r a*era)e monthl' income from
i) 3ainf"l 4mplo'ment Rs
ii) !ther so"rces Rs
$otal Rs
5. ,ate of %irth.ei)ht0eters. 1ei)ht..6)s.
7. .a*e 'o" s"ffered or do 'o" s"ffer from:
(8"ll partic"lars m"st &e )i*en in case the
ans(er is 9+es: to an' of the follo(in) -"eries)
a) An' ph'sical defect or infirmit' +es/No
&) 3o"t or Arthritis or ,ia&etes# Paral'sis. +es/No
c) 8its or an' /ind or an' other chronic disease. +es/No
d) An' other disa&ilit' +es/No
;. (a) .a*e 'o" e*er proposed for Accident
<ife =ns"rance
(&) =f so# )i*er name of each Compan' and
Amo"nt of =ns"rance.
(c) .as an' Compan'
i) ,eclined to iss"e a polic' to 'o">
ii) ,eclined to contin"e 'o"r =ns"rance.
iii) Not in*ited the rene(al of 'o"r Polic'>
i*) =mposed an' restriction or special conditions>
=f so# )i*e names and address of each Compan'
in Respect of =)# ii) and i*) a&o*e.
(d) =s this ins"rance to &e additional i. Name of Co
to an' other Accident Polic' or ii. 2"m ins"red.
4mplo'ee 2cheme: =f so )i*e iii. Polic' No.
Partic"lars of all other policies.
?. .a*e 'o" e*er claimed/recei*ed compensation "nder an' Accident Polic'>
=f so# )i*e f"ll partic"lars# name of ins"rer#
Amo"nt and dates.
@. Please indicate
a) Capital 2"m =ns"red Rs
&) $a&le of co*er $a&le A A %enefit 1 %enefit(1) to i.e.
$a&le %1B%enefit 1 to 4 $a&leCAC# D%1C# D%C !R DCC
$a&le %B%enefit 1 to 5
$a&le CB%enefit 1 to 7
c) Period of =ns"rance 8rom..$o.
(&oth da's incl"si*e)
1E. ,o 'o" (ish to o&tain co*er a)ainst additional
Ris/s mentioned "nder eFtension co*er. =f 'es#
2pecif' (hich !ption 1 !ption 2 !ption 3 !ption 4
1# 0edical 4Ftension
2. Cost of $ra*el for an'
Relaion#friend#collea)"e
3. Cost of $ra*el for =ns"red
Person follo(in) Accident.
4. Cost of s"pportin) items
11. 8A0=<+ PAC6A34 C!G4R
Name of
famil'
mem&ers
Relationship
(ith =ns"red H
A)e
Profession
or
occ"pation
Ann"al
=ncome
$a&le H Capital 2"m
=ns"red
4Ftension
Relation A)e $a&le A# %1#
%# C
C2= 0edical
Cost of
$ra*el
Cost of
2"pportin)
=tems
2
=n case an' mem&er is s"fferin) from an' disa&ilit' or decease# /indl' )i*e f"ll
details
..
= declare that the a&o*e ans(ers are tr"e to the &est of m' /no(led)e and &elief# that = ha*e
disclosed all partic"lars affectin) assessment of the ris/. = a)ree that this proposal and declaration
shall &e the &asis of the con tract &et(een me and this Compan'.
Place:
Pr!"er#" S$%&a'(re
Da'e:
ASSI)NMENT:
=#..,! .4R4%+ A22=3N $.4 0!N=42 PA+A%<4 %+ $.4 =88C!B$!6=!
3eneral =ns"rance Co.<td.# in the e*ent of m' death to 2hri / 2mt /
6"m.....
(Name H Relationship to the =ns"red) and = f"rther declare that his/her/their receipt shall &e
s"fficient dischar)e to the Compan'.
*+ Da'e, '-$"....+++,a/ 0...+.+2000...++..a'..++...
1=$N422: 1.Name H Address:
S$%&a'(re1"
S$%&a'(re 0 '-e Pl$c/ -l,er
C+ PROHI*ITION OF RE*ATES
$he follo(in) is the cop' of 2ection 41 of the =ns"rance Act# 1@3?:
1. No person shall allo( or offer to allo( either directl' or indirectl' as an ind"cement to an'
person to ta/e o"t or rene( or contin"e an ins"rance in respect of an' /ind or ris/ relatin) to
li*es or propert' in =ndia an' re&ate of the (hole or part of commission pa'a&le or an' re&ate
or the premi"m sho(n on the polic' nor shall an' person ta/in) o"t or rene(in) contin"in) a
polic' eFcept an' re&ate as ma' &e allo(ed in accordance (ith the p"&lished prospect"ses or
ta&les of the ins"rer.
2. An' person ma/in) defa"lt in compl'in) (ith the pro*isions of this 2ection shall &e p"nisha&le
(ith fine# (hich ma' eFtend to fi*e h"ndred r"pees.
THE PROPOSAL FORM WILL ALSO INCLUDE SALIENT FEATURES OF THE
SCHEME BEING OFFERRED
3