National Insurance Company Limited
(Subsidiary of General Insurance Corporation of India)
Regd. Office: 3, MIDDLETON STREET, CALCUTTA –700 071
NIWAS YOJANA POLICY
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For Office Use Only
Agency Code : Policy No. : Premium :
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(a ) Proposer’s Name : Phone :
Fax :
(b ) Proposer’s Address :
(c ) Financial Institution’s Name and Address :
(d ) Address of premises to be insured :
(e ) Are there more than one Financial Institution involved :
(f ) The names of Financial Institutions/Employer to be included in the schedule :
(g ) Period of Insurance : From……………………AM/PM
To……………………..12.00 midnight
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SECTION/ DESCRIPTION OF PROPERTY SUM INSURED RATE PREMIUM
CONTINGENCIES (Rs.) (0%) (Rs.)
(Col. 1) (Col. 2) (Col. 3)
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I- FIRE AND ALLIED i) Building (above Plinth) 0.70
PERILS
ii) Owner’s Fixtures & Fittings
iii) Boundary Walls, Gates & Fences
(above Plinth)
iv) Othher Property, if any
v) Sanitary Fittings
vi) Meters and property belong to authorities
like EB, Water Authority etc.
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II- PERSONAL i) Name of the Person
ACCIDENT
ii) Age
iii) Monthly Income
iv) Details of existing deformity/disability
v) Occupation/Designation
vi) Capital Sum Insured (Max. upto S.I. for Sec. I)
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Total Rs.___________________________________
Add: Service Tax____________________________
Net Premium payable Rs.______________________
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Declaration :
I/We hereby declare that the particulars contained herein are true and correct and that no material fact has been withheld, misstated or
misrepresented and also that this Proposal-cum-Schedule forming part of the Company’s standard Policy shall be the basis of contract
between me/us and the Company. I/We further declare that the Sum Insured herein represent the full value of the property described
herein. I/We also agree that in the event of a claim is admitted as payable by the Insurer, the payment is to be made as per the Bank
Clause attached to the Policy.
Place :
Date : Signature of the Proposer
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ASSIGNMENT FOR PERSONAL ACCIDENT SECTION ONLY
I…………………………………………………………………..do hereby assign the moneys payable by National Insurance Company
Limited, in the event of my death to the Financial Institution/s concerned and the residual amount, if any, may be paid through
Bank/Financial Institution of Sri/Smt…………………………………………………………………my……………………………and
I further declare that his/her/their receipt shall be sufficient discharge to the Company.
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Signature of the Loanee Insured
Place :____________________ Date :_________________________
Sl.No.
Name
Address
Signature
1.
2.
The Insurance cover herein applies to Sections shown above and subject to printed Policy wording attached.
Note : The attached Policy and this Proposal-cum-Schedule shall be read together as one contract and any word or
Expression to which a specific meaning has been attached in any part of this Policy or of the Schedule shall
Bear such meaning wherever it may appear.
Signed at…………………………on the ………………………………..day of ………………………………………20 ……………..
For and on behalf of
NATIONAL INSURANCE CO. LTD.
Note : For Legal Interpretation the English version will hold good. Authorised Signatory