The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

PROPOSAL FORM FOR BHAVISHAYA AROGYA
(TO BE FILLED IN BY THE PROPOSER)

FOR POLICY ISSUING OFFICE USE ONLY

FILL IN ALL PARTICULARS IN BOXES IN BLOCK LETTERS. POPOSAL REGISTRATION USE ONE BOX FOR ONE ALPHABET. LEAVE ONE BOX U/W year Group Number Proposal Number
BLANK AFTER EACH WORD. DO NOT SPLIT THE WORD.
USE NEXT LINE Date of Registration

GROUP NAME: M/s MARKETING ORGANISATION

Name of Prospecting Office
GROUP NUMBER: _______
NUMBER OF PERSONS COVERED: _____ Prospecting office Code

NAME OF PROPOSER: 1) Mr. 2) Mis

FIRST:

Inspector's Name

MIDDLE: Agent's Code

Inspector’s Name:
SURNAME: Agent's Code

M F Agent's Licence No __________
MALE/FEMALE (Indicate with a X mark): [a
SHORT NAME: Date of Expire:

UNDERWRITING entry date:

ADDRESS FOR COMMUNICATION:
Entry Date:

PLACE:

PIN CODE:

DATE OF BIRTH MONTHLY INCOME (Rs.) OCUPATION

DAY MONTH YEAR
INSURANCE COVER DESIRED:
POLICY RETIREMENT AGE SELECTED
(Choose from 55-60 only)
SUM INSURED (Rs.)
A S
PAYMENT BY ANNUAL/SINGLE PREMIUM
(indicate with x mark)

PREVIOUS HISTORY OF MEDICAL/HEALTH INSURANCE:
(1) ARE YOU AT PRESENT COVERED UNDER ANY OTHER INSURANCE?
(2) NAME OF INSURER
(3) PERIOD: COMMENCEMENT DATE OF BENEFITS

HAS ANY PROPOSAL FOR THIS INSURANCE OR ANY OTHER SIMILAR INSURANCE BEEN REFUSED OR CANCELLED OR HIGHER PREMIUM CHARGED? IF SO. GIVE DETAILS

PAYMENT DETAILS:
PREMIUM AMOUNT Rs._______________
AMOUNT IN WORDS_________________________
MODE OF PAYMENT: CHEQUE OTHER

INSTRUMENT NO.__________ DATE:____________

DRAWN ON: ________________________

(Name of Bank & Branch)

Date of Birth:
Entry Age (Completed Year)
Retirement Age

(Selected by Proposer) ______

Premium Mode: Single/Annual Payment

Tabular Premium Rs. _________
for SA Rs.50.000

Sum Assured Rs. _________

Policy Premium S.A. x T.P.

Group Discount Rs.
(If any)

Net Rs. ____________

Age Proof Accepted Yes No

Occupation Code

State Code Centre Code

COLLECTION PARTICULARS
Receipt/ Collection No.

Date of Receipt / Collection

D D M M Y Y

AMOUNT COLLECTED
Rs.

_______________________
Signature of Cashier

DECLARATION

I _____________________________________________(NAME OFTHE PROPOSER) hereby declare and warrant that the above statements are true and complete. I agree that this proposal shall form the basis of the contract should the insurance be effected. If after the insurance is effected, it is found that the statements, answers or particulars stated in the proposal form and its questionnaire are incorrect or untrue in any respect the Insurance Company shall be undergo liability under this insurance.

I have read the Prospectus and am willing to accept the coverage subject to the terms, conditions and exceptions prescribed by the Insurance Company therein

Date: D M Y Signature of the Proposer__________________

ASSIGNMENT OF POLICY MONIES:

I .......................................................... do hereby assign the monies payable by the Insurance Company in the event of my death to my .....................aged ........... years
(Relationship)

ASSIGNEE'S NAME

Assignee's Address for Communication:

PIN:

I further declare that the assignee's receipt shall be sufficient discharge to the Company.
Dated this _____________day of _______________ 200 at______________

Witness:
Signature: __________________ Signature of the Proposer: ________________

Name & Address

Specimens Signature of the Proposer: Specimen Signature of the Proposer:

PROHIBITION OF REBATES

Section 41 of 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 rebate except such rebate as may be allowed in accordance with the published prospectus or tables of the Insurer.
2. Any person making default in complying with the provision of this Section shall be punishable with fine which may extend to five hundred rupees.