Name of the Insured

Communication address

Type of policy Motor

Private car
Commercial vehicle
Policy period

Vehicle Number

IDV of the vehicle

Claim if any in previous year

I/We HEREBY DECLARE AND WARRENT that the above statement are true and complete.
I/We desire to affect an insurance with the Company through Invictus Insurance Broking Services
Pvt.Ltd and I/We agree that this proposal and declaration shall be the basis of the contract between
me/us the Company and I/We agree to accept a policy subject to the conditions prescribed by the
Company.

Place……………………. Date……………….. Proposer’s Signature…………………….