UNITED INDIA INSURANCE CO LTD
STANDARD PROPOSAL FORM FOR “LIABILITY ONLY” POLICY
(For Private Cars / Two Wheelers)

A.Questions that are necessarily to be listed for granting the cover as per the Motor Vehicles Act1988.
A (I). Personal Details of Proposer/Owner:
Pe
rs
on
al
D
et
ail
s
1 Proposer’s (Owner’s) Full
Name
(In capital letters)
2 Address (where the
vehicle is normally kept)
(In capital letters,
with pin code) PIN:
Telephone: Fax:
Mobile No: Mail Id:
3 Occupation / Business
4 Type of Cover Liability Only Policy
5 Period of Insurance
From: _______ Hrs on _____/_____/________
To : _______ Hrs on ____/____/__________
A (II). Vehicle Details
Ve
hi
cl
e
Sp
ec
ifi
ca
ti
on
s
6 Registration Number of the Vehicle
7 Date of Registration of the Vehicle
8 Registering Authority & Location
9 Year of Manufacture
10 Engine Number
11 Chasis Number
12 Make of the Vehicle
13 Model
14 Type of Body
15 Cubic Capacity of the Vehicle
16 Seating Capacity including driver
17 Whether the vehicle is driven by nonconventional
source of power / CNG /
LPG / Bi-Fuel ?
If ‘YES’, please give details
18 Whether the use of vehicle is limited to own
premises?
YES NO
19 Whether the vehicle is used for commercial purpose? YES NO
20 Whether the vehicle is used for driving tuitions?
(GR-44)
YES NO
21 Details of Hire Purchase / Hypothecation / Lease (IMT-5)
a) Is the vehicle proposed for insurance is:
(i) Under Hire Purchase? YES / NO
(ii) Under Lease Agreement? YES / NO
(iii) Under Hypothecation? YES / NO
b) If ‘YES”, give name and address of concerned party/parties:
A (III). LIABILITY SECTION: COVERAGE
Third
Party
Risks:
Death
/
Bodily
Injury
22 Coverage for liability against Third Party Risks (Death or Bodily Injury)
required in respect of:
(i) Owner Driver only YES / NO
(ii) Any person other than Paid Driver YES / NO
If ‘YES”, give details of such other persons:
1.
2.
3.
(Note:
1. Section146 of Motor Vehicles Act-1988 makes it mandatory for the owner
of the vehicle to ensure that he or any other person authorized by him to
drive a vehicle in public place has insurance against third party risks. The
explanation to Section146 exempts the paid driver.)
2. As per Section 147 (2)(a) The liability is ‘as incurred’ in the case of death
/ bodily injury of a third party]
Third
Party
Risks:
TPPD
(IMT-
20)
23 Do you wish to have the statutory Third Party Property Damage (TPPD)
liability of Rs.6000/- only?
YES / NO
[For additional TPPD limits, please see Q.No.25]
Third
Party
Risks:
Liabilit
y to
'Work
men'
under
W.C.Ac
t-1923
(Comp
ulsoril
y
to be
covere
d by
M.V
Act-
1988)
24 Legal liability to persons employed in connection with operation of the
vehicle who are ‘workmen’. [The liability of the Employer under the
Workmens’ Compensation Act-1923 is covered under the Motor Vehicles
Act-1988.
1) Drivers (No.of persons: _______)
2) Employees (Workmen) (No.of persons: _______)
(Note: The Motor Vehicles Act-1988 under Sec.147(1)(ii)(i) covers liability
to employees who are workmen within the meaning of the Workmen’s
Compensation Act-1923.)
For additional coverage, please refer to Q.No.26]
B. Questions that provide additional covers as per IMT Endorsements
Addl.
TPPD
25
(
G
R
-
3
9
)
The Policy provides additional Third Party Property Damage liability limits of
Rs.1,00,000/- for Two Wheelers and Rs.7,50,000/- for other classes of vehicles.
Do you wish to cover the additional limit?
YES / NO
[Refer to Q.No.23]
Additio
nal
Liabilit
y to
Workm
en
26
(
I
M
T
-
2
8
)
Do you wish to cover wider legal liability to employees who are ‘workmen’? [This
information is sought to cover in addition to liability under the Workmens
Compensation Act-1923, also liability under the Fatal Accidents Act-1855 and the
Common Law]
YES / NO
(Note: The additional liability under Common Law and Fatal Accidents Act in
respect of employees who are workmen is covered under this endorsement).
[Refer to Q.No.24]
Liabilit
y to
Employ
ees
who
are not
Workm
en
27
(
I
M
T
-
2
9
)
Do you wish to cover wider legal liability to employees who are NOT ‘workmen’?
YES / NO
(Note: The liability under Common Law and Fatal Accidents Act-1855 in respect
of employees who are not workmen can be covered under this endorsement).
Person
al
Accide
nt
Cover
For
Owner
Driver
28
Personal Accident Cover for Owner Driver is compulsory in the Liability Only
Cover. Please give details of nomination:
(a) Name of the Nominee & Age :
(b) Relationship :
(c) Name of the Appointee
(If Nominee is a Minor) :
(d) Relationship to the Nominee :
(Note: 1. Personal Accident cover for Owner Driver is compulsory for Sum
Insured of Rs.1,00,000/- for Two Wheelers and Rs.2,00,000/- for Private Cars.
2. Compulsory PA cover to owner driver cannot be granted where a vehicle
is owned by a company, a partnership firm or a similar body corporate or where the
owner-driver does not hold an effective driving license)
PA
Cover
for
Name
d
Occup
ants
29
(
I
M
T
-
1
5
)
Do you wish to include Personal Accident cover for named persons?
YES / NO, If YES, give name and Capital Sum Insured (CSI) opted for:
Name CSI Opted
(Rs.)
Nominee Relationship
1)
2)
3)
(Note: The maximum CSI available per person is Rs.2 Lakhs in case of Private
Cars and Rs.1 Lakh in the case of Motorized Two Wheelers)
PA
Cover
for
Un-
Named
Occupa
nts
30
(
I
M
T
-
1
6
)
Do you wish to include Personal Accident cover for Un-named
Passengers/hirer/pillion passengers (Two Wheelers)?
YES / NO
If YES, give number of persons and Capital Sum Insured (CSI) Opted:
No. of Persons: ________ C.S.I (Per Person):________________
(Note: The maximum CSI available per person is Rs.2 Lakhs in case of Private
Cars and Rs.1 Lakh in the case of Motorized Two Wheelers)
Geogra
phical
Extensi
on
31
(
I
M
T
-
1
)
Whether extension of geographical area to the following countries required?
(1) Bangladesh YES / NO (2) Bhutan YES / NO
(3) Maldives YES / NO (4) Nepal YES / NO
(5) Pakistan YES / NO (6) Sri Lanka YES / NO
(Note: Presently the territory covered is geographical area of India. Extension of
geographical area cover can be availed by use of this endorsement
C. Questions that are elicited for information and data collection purposes
Previo
us
History
32 Previous History:
a. Date of purchase of the vehicle by the Proposer: ____/____/_________
b. Whether the vehicle was new or second hand
at the time of purchase? : New / Second Hand
c. Will the vehicle be used exclusively for
(i) Private, Social, Domestic, Pleasure &
Professional Purpose? YES / NO
(ii) Carriage of goods other than samples
or personal luggage? YES / NO
d. Is the vehicle is in good condition? YES / NO
If NO, please give details:
e. Name and Address of the previous insurance company:
f. Previous policy number: ___________________
g. Period of Insurance : From:____________ To:______________
h. Claims lodged during the preceding 3 years:
YEAR NO.OF CLAIMS CLAIM AMOUNT (Rs.)
___________ ________________ ______________________
___________ ________________ ______________________
___________ ________________ ______________________
Driver
Details
33 Details of the Driver:
a. Age & Date of Birth of the Owner: Age:_____Yrs DOB:___/___/______
b. Age & Date of Birth of the Driver: Age:_____Yrs DOB:___/___/______
c. Does the driver suffer from defective
vision or hearing or any physical infirmity? YES / NO
If YES, please give details of such infirmity:
d. Has the driver ever been involved / convicted
for causing any accident of loss? YES / NO
If YES, give details as under including the pending prosecutions:
- Driver’s Name :
- Date of Accident:
- Loss / Cost (Rs.):
- Circumstances of Accident / Loss:
Declaration by the Insured
I/We hereby declare that the statements made by me/us in this Proposal Form are true to the best
of my/our knowledge and belief and I/We hereby agree that this declaration shall form the basis of
the contract between me/us and the United India Insurance Company Ltd.
I/We also declare that any additions or alterations are carried out after the submission of this
proposal form then the same would be conveyed to the Insurance Company immediately.
Place:
___________________________
Date : Signature of the Proposer/s.
PROHIBITION OF REBATES (Insurance Act-1938, Section 41)
1. 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 or part of the commission payable or
any rebate of the premium shown in the policy, nor shall any person taking out of renewing
or continuing a policy accept any rebate except such rebate as may be allowed in
accordance with the prospectus or tables of the Insurer.
2. Any person making default in complying with the provisions of this section shall be
punishable with fine which may extend to five hundred rupees.
Note: Denial of "Third Party Liability Only Cover" by Insurer, for
reasons other than fraud/misrepresentation by proposer, will entail
Regulatory action.