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

GOLFERS INDEMNITY PROPOSAL FORM

1. Proposer’s Name :
2. Address :

3. Age and Occupation :
4. Name and Address of the Golf Club :
5. Are you already insured with any
Company in respect of Personal Accident ?
If so, for what amount and the type of
Cover.
6. Has any claim been made against you in the
past ?
If so, give full details.
7. Has any application for insurance made by
you ever been decline ?
8. Amount of indemnity required in respect of
third parties :
9. Amount of insurance required in respect of
Personal Accident :
10. Attach a list of articles in Golf Kit to be
insured and values thereof.
I declare that the above statements are true and I am in good health; and free from any physical infirmity or defect and I agree that this proposal shall be taken as basis of the proposed contract between me and The New India Assurance Company Limited and I agree to accept a policy in the Company’s usual form for this class of insurance.

Date : Signature of the Proposer
Note 1.The liability of the company does not commence until the proposal has been accepted by the
Company and full premium paid.
2. If space is found insufficient, please attach separate sheets for details.
3. Insurance is the subject matter of solicitation.
4. Premium will be quoted on application.
PROHIBITION OF REBATE -- Section 41 of the Insurance Act 1938
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 of risk relating to lives or property in India, any rebate of the whole 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 any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Five Hundred Rupees.