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

JANATA PERSONAL ACCIDENT POLICY

PROPOSAL FORM

1. Name of Proposer Mr/Mrs: ______________________________________________

2. Full Address: _________________________________________________________

_________________________________________________________

3. Age: _________________________ 4. Date of Birth: _________________________

4. Occupation: ____________________ 6. Annual Income: Rs.____________________

7. If there is any disability Please specify: _____________________________________

8. Name of nominee: _____________________________________________________

9.His/Her Age: __________________________________________________________

10. Relation with Insured: _________________________________________________

11. His/Her full address: __________________________________________________

___________________________________________________

12. Witness to Nomination: ________________________________________________

a) Name: 1) ___________________________ 2) ____________________________

b) Address: 1) _________________________ 2) ____________________________

________________________ ____________________________
13. Capital Sum Insured: Rs. _________________________________________________
14. Policy Period (1 year to 5 years) ___________________________________________
15. Period of Insurance: From _______________________ to _____________________

Date: _________

Place: ___________ Proposer’s Signature