NATIONAL INSURANCE COMPANY LIMITED
(Subsidiary of General Insurance Corporation of India)

Regd. Office : 3, Middleton Street, Calcutta – 700 071.
PROPOSAL FORM FOR
COMMERCIAL VEHICLE INSURANCE
Address of the Policy Issuing Office
NOTE
1. All questions should be answered in full. Ticks or
dashes will not suffice.
2. Acceptance of this Proposal is subject to the rules
and requlations of the Indian Motor Tariff and no
liability is undertaken until the proposal has been
accepted by the Company and the premium paid.
For Office use only
Policy No. ................................................................
Premium Rs. ............................................................
Risk Date ........................... Time ...........................
Receipt No .............................................................
Agency Code .........................................................
1. Full name of the Registered Owner of the Motor
Vehicle (Proposer) :
2. Business / Occupation :
3. Address of the Proposer :
Place of Business / Occupation For Communication
4. Purpose for which the vehicle will be used (delete which is not applicable)
Transportation of goods
Own goods For public
Transportation of Passengers for
hire/reward
For other purpose (detailed
hereunder)
5. Particulars of the Motor vehicle proposed for Insurance
As per Certificate Registered of registration
Letters &
Numbers
Make &
Type of
Body
Year of
Manufacturer
Chassis
No.
Engine No.
Gross
Vehicle
Weight in
Kgs
Cubic
Capacity
Licensed
Passenger
carrying
capacity
6. Full Address of the Registration
Authorities
7. Please State the Type of Cover required (delete which is not applicable)
Act Liability only Extended Act Liability i.e.
Third Party
Extended Act Liability plus
Fire and/or Theft cover
Extended Act Liability plus
own Damage
8. Particulars of the existing / previous policy covering the vehicle proposed for insurance (not necessary in case of a
new vehicle)
Claims lodged during Name and the preceeding 3 years
Address of
the policy
issuing office
Policy
Number
Period of
Insurance
Type of
Cover
Year No. Amount
9. Period of Insurance From ......................................... To ............................................ (Please refer Note 2 above)
________________________________________________________________________________________________
THE FOLLOWING QUESTIONS ARE TO BE ANSWERED, IF COVER MORE THAN ACT LIABILITY OR
EXTENDED ACT LIABILITY IS REQUIRED.
________________________________________________________________________________________________
10. If any Financing Institution / or any other person is interested in the vehicle proposed for insurance, please give
the name and address of the same.
Under Hire Purchase Agreement Under Lease Agreement Under Hypothecation Agreement
11. Please state the following Premium Computation
for Office use only
a) Estimated present value of the vehicle Rs.
b) Estimated value of non-electrical items like neckrest, Rs.
sunvisor etc. Fitted to the vehicle
c) Estimated value of the electronic / electrical items fitted
To the vehicle Rs.
Tape
Recorder
Rs.
Air
Conditioner
Rs.
Fan
Rs.
Musical
Horn
Rs.
Rs.
11. Please state the following (Contd.) Premium Computation
For Office use only
d) Does the Proposer wish to opt out any of the extraneous perils ?
i) Riot, Strike & the Terrorist activity Yes / No
ii) Earthquake (fire & shock damage) Yes / No
iii) Flood, Typhoon, Hurricane, Storm, Inundation,
Cyclone, Hailstorm, Frost Yes / No
e) In case of contract carriage, whether the vehicle shall operate
within a radius of 50 kms from the city limits Yes / No
f) Will the vehicle be driven by named driver ?
If yes, please state the details of the drivers as follows Yes / No
Rs.
Sl.No
.
Name Age Driving Licence
No. and date of
expiry
Period of driving
experience
g) In addition to compulsory excess, does the Proposer wish to
bear the first of each and every claim for loss of or damage
to the Vehicle ? Yes / No
Rs. 1000 Rs. 2500 Rs. 5000 Rs. 7500 Rs. 10000
h) Is the Proposer from the Previous Insurer,
i) Entitled to a No Claim Discount Yes ..................% No
ii) Subject to malus ? Yes ................% No
Premium for own damage Total
Rs.
12 a) Does the Proposer desire Additional liability cover for Third Party
property damage in excess of Rs. 6,000/- ? (as is available under the Motor
Vehicles Act)
Yes ................................... Rs................................ / No
b) Does the proposer wish to insure the employees against wider legal liability
?
Yes, No. of Persons ................................. / No
c) In respect of goods carrying vehicle, does the Proposer wish to insure in
respect of more than six (6) employees ?
YES, No. of Persons ................................... / No
13. Please give the following particulars in respect of the Trailers, if any.
a) Maximum number of trailers to be towed at any one time by the towing vehicle
_________________________________
b) Total number of trailers to be insured
__________________________________________________________________
c) Registered Letters & No.
___________________________________________________________________________
d) Licensed goods carrying capacity
_____________________________________________________________________
e) Estimated value for insurance Rs.
____________________________________________________________________________
14. In respect of the Proposer & the vehicle proposed for insurance has, any Insurance Company ever
Declined Proposal Cancelled & refused to
renew the policy
Required an increased
premium
Imposed special condition
or excess
YES / NO
YES / NO
YES / NO
YES / NO
THE FOLLOWING QUESTION IS REQUIRED TO BE ANSWERED, IF THE COVER IS REQUIRED NOT BY
AN INDIVIDUAL
________________________________________________________________________________________________
15. Whether the owner sof the Vehicle is :
i) a Private Limited Company or a Public Sector Undertaking or a Satutory Body
with a paid up capital of Rs. 10 lacs or above. YES /
NO
ii) a Co-operative Society with a paid up capital of Rs. 5 lacs or above. YES / NO
iii) a Charitable Trust whose income is exempted from Income Tax. YES / NO
________________________________________________________________________________________________
In case of payments by cheque, please state Cheque No. ..................................... .............. date
......................................... .......drawn on ......................................................... for Rs. ..............................
________________________________________________________________________________________________
Declaration
I/We desire to insure with NATIONAL INSURANCE COMPANY LIMITED, in respect of the vehicle described
above thereby warrant that the Statements and Particulars given above are true, and I/We have not suppressed,
misrepresented or mis-stated any material fact.
I/We agree that this Proposal and declaration shall be held to be promissory and shall be the basis of the contract
between me/us and National Insurance Company Limited, and agree to accept the Company’s usual form of Policy for
insurance of this nature. I/We undertake that the vehicle to be insured shall not be driven by any person who to my / our
knowledge has been refused any Motor Vehicle Insurance or continuance thereof.
Date ............................ Signature of the Owner of the Vehicle
________________________________________________________________________________________________
___________
Seal & Signature of Bank / Financing Name and Signature of the person completing
Institution and date this Proposal if it differs from the Proposer
Name & Signature of Agent / Inspector Agent Code No.
Skd./ motor commercial