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

PROPOSAL FORM FOR JANATA PERSONAL ACCIDENT INSURANCE POLICY WITH MEDICAL EXPENSES ARISING OUT OF ROAD ACCIDENT (RASTA APATTI KAVACH)

1. Name of the Insured

2. Full Address

3. Age: 4. Date of Birth: 5. Occupation:

6. Annual Income Rs.: 7. If there is any disability, please specify:

8. Capital Sum Insured in respect of insured: Rs.: Category:

Category a. b. c. d.
Section I
II Rs.1, 00,000
Rs.1, 00,000 Rs.75, 000
Rs.75, 000 Rs.50, 000
Rs.50, 000 Rs.25, 000
Rs.25, 000

A) No of Unnamed Passengers in Vehicle______For Section ll. Category a, b/c/d
B) Third Party injury whilst the insured using his own vehicle-No of Persons _____For Section II, Category a/ b/c/d

(N. B. Please fill/in number of unnamed passengers & also number of persons for whom the Third Party are to be covered whilst insured using his own vehicle. Mention the category of Sum insured choosen.

9. I ..........................................do hereby assign the money payable in the event of my death by The New India Assurance Co. Ltd. to Mr./ Mrs........................... and I further declare that his/her receipt shall be sufficient discharge to the Company.

10. Nominees Age: Relation lo the insured:

11. Nominees' full Address

12. Period of Insurance ______years (1 to 15) from ____________to____________

Witness 1 2
1. Name:
2. Address:

Dated this....................day...........200 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.