NATIONAL INSURANCE COMPANY LIMITED
(Subsidiary of General Insurance Corporation of India)
Regd. Office : 3, Middleton Street, Calcutta – 700 071.

PROPOSAL FORM FORMOTOR CYCLE / SCOOTER INSURANCE

NOTE
1. All questions should be answered in full. Ticks or
dashes will not suffice.
2. Acceptance of this Proposal is subject to the rules
and regulations of the Indian Motor Tariff and no
liability is undertaken until the proposal has been
accepted by the Company and the premium paid.
3. The term Motor Cycle will include Motor Scooter
and/or Auto Cycle.
For Office use only
Policy No. ................................................................
Premium Rs. ............................................................
Risk Date ........................... Time ...........................
Receipt No .............................................................
Agency Code .........................................................
1. Full name of the Registered Owner of the Motor
Cycle / Scooter (Proposer) :
2. Business / Occupation :
3. Address of the Proposer :
Place of Business / Occupation For Communication
4. Purpose for which the Motor Cycle will be used :
________________________________________________________________________________________________
5. Particulars of the Motor Cycle proposed for Insurance :
Registered
Mark &
Numbers
Make & Type
of Body
Chassis No. Engine No. Cubic
Capacity
Year of
Manufacture
Seating
capacity of the
Side Car, if
attached
6. Full Address of the Registration
Authorities
7. Please State the Type of Cover required (delete which is not applicable)
Act Liability only Extended Act Liability i.e. Third
Party
Extended Act Liability
plus Fire and/or Theft
cover
Extended Act Liability
plus Own Damage
8. Particulars of the existing / previous policy covering the Motor Cycle proposed for insurance (not necessary in
case of a new Motor Cycle)
Claims lodged during Name and the preceeding 3 years
Address of
the Policy
Issuing Office
Policy
Number
Period of
Insurance
Type of
Cover
Year No. Amount
9. Period of Insurance From ......................................... / To ............................................ (Please refer Note 2 above)
________________________________________________________________________________________________
THE FOLLOWING QUESTIONS ARE TO BE ANSWERED, IF COVER MORE THAN ‘ACT LIABILITY OR
EXTENDED ACT LIABILITY ‘ IS REQUIRED.
________________________________________________________________________________________________
10. If any Financing Institution / or any other person is interested in the Motor Cycle proposed for insurance, please
give the name and address of the same.
Under Hire Purchase Agreement Under Lease Agreement Under Hypothecation Agreement
11. In respect of the Proposer & the Motor Cycle proposed for insurance has, any Insurance Company ever :
Declined Proposal Cancelled & refused to
renew the policy
Required an increased
Premium
Imposed special condition
or excess
YES / NO YES / NO YES / NO YES / NO
12. The Motor Cycle will
be driven by (delete which
is not applicable)
The owner
Any particular person
Any Person
13. Does the owner or that person who will drive
a) Suffer from defective vision or hearing or from any physical infirmity ? YES / NO
b) Have you ever been convicted in the past for causing accident ? YES / NO
14. Please state the following Premium Computation
for Office use only
a) Estimated present value of the Motor Cycle Rs.
Side Car if any Rs.
b) Estimated value of non-electrical items like neckrest, Rs.
sunvisor etc. Fitted to the Car
Rs.
c) Does the Proposer wish to opt out any of the extraneous perils ?
i) Riot, Strike & the Terrorist activity Yes / No
ii) Earthquake (fire & shock damage) Yes / No
iii) Flood, Typhoon, Hurricane, Storm, Inundation,
Cyclone, Hailstorm Yes / No
d) Does the Proposer wish to bear the first of each and
every claim for loss of or damage to the Motor Cycle ?
(Please strike out which is not applicable) Yes / No
Rs. 100 Rs. 200
e) Is the proposer (if an individual) a member of any
recognised Automobile Association in India ? YES / NO
If yes, please state
Rs.
Name of the Association Membership No. Date of Expiry
f) Is the Proposer , from the Previous Insurer,
i) Entitled to a No Claim Discount Yes ..................% No
ii) Subject to malus ? Yes ................% No
Premium for own damage Total
Rs.
15. a) Does the proposer wish to insure for Personal Accident Benefits in respect of ?
Owner of Car ( if an
individual)
Named or unnamed Pillion rider
Sum Insured Rs.
YES / NO YES / NO
In case of named Pillion riders please state
Name of the Pillion rider
Age
b) Does the proposer wish to insure the Operator/Cleaner against wider legal
liability?
Yes
No. of persons No.
THE FOLLOWING QUESTION IS REQUIRED TO BE ANSWERED, IF THE COVER IS REQUIRED NOT BY
AN INDIVIDUAL
________________________________________________________________________________________________
16. Please give the address where the Motor Cycle will usually be garaged after the business hours
________________________________________________________________________________________________
17. Whether the owner of the Motor Cycle is :
i) a Private Limited Company or a Public Sector Undertaking or a Statutory Body
with a paid up capital of Rs. 10 lacs or above. YES / NO
ii) a Co-operative Society with a paid up capital of Rs. 5 lacs or above. YES / NO
iii) a Charitable Trust whose income is exempted from Income Tax. YES / NO
________________________________________________________________________________________________
In case of payments by cheque, please state Cheque No. ..................................... .............. date
......................................... .......drawn on ......................................................... for Rs. ..............................
________________________________________________________________________________________________
Declaration
I/We desire to insure with NATIONAL INSURANCE COMPANY LIMITED, in respect of the Motor Cycle described
above hereby warrant that the Statements and Particulars given above are true, and I/We have not suppressed,
misrepresented or mis-stated any material fact.
I/We agree that this Proposal and declaration shall be held to be promissory and shall be the basis of the contract
between me/us and National Insurance Company Limited, and agree to accept the Company’s usual form of Policy for
insurance of this nature. I/We undertake that the Motor Cycle to be insured shall not be driven by any person who to
my / our knowledge has been refused any Motor / Vehicle Insurance or continuance thereof.
Date ............................ Signature of the Owner of the Motor Cycle
________________________________________________________________________________________________
Seal & Signature of Bank / Financing Name and Signature of the person completing
Institution and date this Proposal if it differs from the Proposer
Name & Signature of Agent / Inspector Agent Code No.
Skd./ motor cycle