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

PROPOSAL FORM DOG INSURANCE (CANINE INSURANCE)

SCOPE OF SCHEME: Dogs are insured against death due to accident and/or diseases contacted during the period of insurance subject to usual terms, conditions and exclusions of policy.

A. Insured’s Name: ______________________________________________________

B. Insured’s Address: _____________________________________________________

_____________________________________________________

C. Date of Proposal & Declaration: __________________________________________

D. Description of the dog/s:

(1) Total No. of dogs__________________________________________________

(2) No. of the dogs per unit: ___________________________________________

(3) Identification: ___________________________________________________

(4) Variety of type of dogs: ___________________________________________

(5) Date of purchase: ________________________________________________

(6) Source of purchase: ______________________________________________

(7) Age of dogs covered: _____________________________________________

E. SUM INSURED Rs. _____________________________________________

F. Location of the place where the dogs are housed /kenneled: __________________

G. Vaccination particulars: _______________________________________________

H. Any other information: _______________________________________________

I/WE hereby propose to insure the abovementioned dog/s owned by me/us with THE NEW INDIA ASSURANCE CO. LTD. subject to the terms, conditions and exclusions of the Company’s policy.

I/WE warrant that the answers to the above queries are true and that all the dog/s are correctly described are sound, in good health and free from vice. I/WE declare that no information material to the insurance has been withheld and agree that this proposal shall be the basis of the contract between me/us and the Company.

Date: _______________ ____________________

Place: ______________ Signature of the proposer