UNITED INDIA INSURANCE COMPANY LIMITED
MOTOR INSURANCE PROPOSAL FORM
Commercial / Miscellaneous Type - PACKAGE POLICY

Development Officer’s Name &
Code :
Broker’s / Agent’s Name & Code
:
Proposer’s Name
Address for Correspondence
Telephone & Fax Number Mobile No:
E-mail Address
Bank Account No. (SB/Current
Account)
PAN No:
HPA/Hypothecation
Type of Policy Required Package Policy
Period of Insurance From Time ------- Date : To
Details of Vehicle
Regn.No. Eng.No.&
Chassis No.
Year
of
Make
Make&
Model /
Type of
Body
Cubic
Capacity/
HP
Seating
Capacity
Gross
Vehicle
Weight
Fuel Used
Value of the Vehicle:
Invoice-
Value
Electric/
Electronic
Accessories
NonElectrical
Accessories
Trailer LPG/CNG
Kit
Total Value IDV
History of Vehicle:
Previous
Policy No
Type of
cover
Name of Insurer &
Place
Entitlement
of No Claim
Bonus
Date
of
Expiry
Claim
Experien
ce for
last 3
years
Date of first Purchase &
Regn.
Usage of the Vehicle:
Nature of Permit National/Zone/State Details of Driver Self/Paid
Private Carrier Name & Age
Public Carrier Driving License No &
Type
Stage/Contract
Carriage
Bus/Taxi/Auto
Maxicab
Date of Expiry
Miscellaneous types of
vehicle
No. of accidents
involved
Has any Insurance Company declined your proposal or cancelled your Motor Policy
Discounts & Loading:
Is the vehicle fitted with the any Anti-Theft
Device approved by ARAI
Yes/No If yes, attach certificate of installation issued by AASI
Whether the vehicle is driven by nonconventional
source
Yes/No If yes, please specify the details
Whether the vehicle is driven by Bi-fuel kit /
Fibre Glass Tank Fitted
Yes/No If yes, please specify the details
Do you wish to restrict TPPD cover to Statutory limit
of Rs.6000/-only
Yes/No
Extra Covers required
Legal Liability to Driver, Cleaner, Conductor
Legal Liability to Other Workmen
Legal Liability to Non Fare Paying Passengers
Legal Liability to Passengers
PA cover to Driver/Cleaner/Conductor
Compulsory Personal Accident Cover for Owner Driver
Personal Accident Cover for Owner Driver is compulsory. 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 Rs.2,00,000/-
for Commercial Vehicles.
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)
P A Cover for Named Persons
Named OccupantsPA Cover for
(IMT-15)
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 of
Commercial Vehicles )
PA to unnamed hirer/driver
Do you wish to have Nil Depreciation Add –on
Cover?
Other Details
Whether use of vehicle is confined to sites Yes/No
Whether the vehicle is designed for use of
blind/handicapped/mentally challenged persons
Yes/No If yes, please specify the details of Endorsement by
RTA
Whether the vehicle is used for Driving Tuitions Yes/No
Do you wish to cover overturning risk? (applicable to
cranes, mechanical navies, shovels, grabs, rippers,
excavators, dragline excavators, mobile drilling rigs
and mobile plant)
Yes/No
Whether extension of Geographical Area is
required
Yes/No If yes, State the Name of the Country Nepal Bangaladesh,
Bhutan, Maldives, Pakistan, SriLanka
Driver Details
Name Age DL No., Date of first issue
and Issuing Authority
Type of
licence held,
Badge number
Endorsements Details of physical infirmities,
if any
‘Do you wish to have a One Page Policy : Yes / No
(Policy terms and conditions can be viewed at our website : www.uiic.co.in)
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 his declaration shall form the basis of the
contract between me/us and the UNITED INDIA INSURANCE CO. LTD.
I/We also hereby declare that any additions or alterations carried out after the submission of this
Proposal Form then the same would be conveyed to the Insurers immediately.
I/we wish to confirm that there has been no accident to my/our vehicle since the last Policy Expiry
Date till now. I/We confirm that I/We have remitted the premium at……………………………
on…………………. For the insurance of the above vehicle with you. It is understood and agreed that
you have no liability or whatsoever nature for any Loss/Damage/Liability arising out of any accident
earlier to ……………..(time).
I/We declare that the vehicle is in perfect state and roadworthy condition..
Place :
Date : SIGNATURE OF THE PROPOSER