NATIONAL INSURANCE COMPANY LIMITED
(A subsidiary of General Insurance Corporation of India )
Regd. Office : 3, MIDDLETON STREET, CALCUTTA – 700 071

For Office use only :
Policy No. :
Premium : Rs.
Agency Code :

PROPOSAL FORM CUM POLICY SCHEDULE FOR AMARTYA SIKSHA YOJANA INSURANCE POLICY

1.
i) Name of the Providing Parent/Legal Guardain :
ii) Age, Height & Weight :
iii) Address :
iv) Profession/Occupation/Trade/Business :
v) Present/Physical Infirmity, if any :
2. Name of Student Child : i)
ii)
3. Course Details
i) Name of Course :
ii) Name of Institution :
iii) With whom the Course/Institution is
Affiliated (Board/University etc.) :
iv) Duration of course :
v) Give Estimated Figures in respect of the
following (For the entire duration of the
course) :
( Give only such figures for which Receipts are issued / and excluding the first admission fee )
______________________________________________________________________________________
Course / Tution Fee Hostel Fees Other Expenses Amount
______________________________________________________________________________________
______________________________________________________________________________________
vi) when admitted to the course :
4. Sum Insured opted for :
5. In case of Group Policy to be taken by the School, College or Institution, Please furnish a list of all
students and their Parent / Legal Guardian alongwith all the above information vide a separate sheet.
It is hereby declared and agreed that in the event of death of the providing Parent / Legal Guardian i.e. the
undersigned insured in the circumstances giving rise to a valid claim under the Policy the Sum Insured
under the clause shall be payable to Shree ......................
................................................................................ in accordance with the legal assignment, dated
.......................... duly executed by the undersigned which is deemed to be incorporated under the policy.
Discharge to the Company by the said Shri / Smt ...........................................................................................
shall be sufficient and legally binding discharge to the Company of all claims under the relevant clause of
the policy.
Subject otherwise the terms, provisions and conditions of this policy.
Date of Proposal
And Declaration :
______________________________
Signature of
Providing Parent / Guardian
Place :
______________________________________________________________________________________
Subject to printed policy wording attached.
Note : The attached Policy and this Schedule shall be read together as one contract and any word, or
expression to which a specific meaning has been attached in any part of this policy or of the Schedule shall
bear such meaning wherever it may appear.
In witness whereof this Policy has been signed at
........................................................................................................................ on the
................................................. day of ........................................ 20
For and on behalf of
NATIONAL INSURANCE COMPANY LIMITED.
Authorised Signatory
Skd./ amartya siksha proposal policy