UNITED INDIA INSURANCE COMPANY LIMITED
MOTOR INSURANCE PROPOSAL FORM
PRIVATE CAR / TWO WHEELER - PACKAGE POLICY

MOU / Development Officer : Dealer /
Broker /Agent 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.&
Chas. No.
Year of
Make
Make&
Model /
Type of
Body
Cubic
Capacity
Seating
Capacity
Colour Fuel
Used
Registering Authority - Name and location :
Value of the Vehicle:
Invoice
Value
Electric /
Electronic
Accessories
Non-
Electrical
Accessorie
s
Side
Car/Trailer
LPG/CN
G Kit
Total Value IDV
History of the Vehicle
Previous
Policy
No
Type of
cover
Name of
Insurer &
Address
Entitlement
of No Claim
Bonus
Date of
Policy
Expiry
Claim
Experience
for last 3
years
Date of first
Purchase & Regn.
Usage of the Vehicle:
Purpose of Use Details of
Vehicle Parking
Details of Driver Average km run in a year
Pleasure Covered Garage Self
Professional Uncovered Garage Paid Driver
Business/Trade Within the Compound Relatives
Corporate Roadside Friends
Discounts & Loading:
Voluntary Excess: Do you wish to Opt
for Voluntary Excess over and above
the Compulsory Policy Excess
Yes/No – If yes, please specify the amount Two
Wheeler – Rs.500/700/1000/1500/3000 Private
Are you a member of
Automobile Association of
India
Yes/No If yes, please State:
1. Name of Association
2. Membership No: Date of Expiry :
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
non-conventional 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
Additional covers required
Theft of Accessories (Two wheelers only)
Legal Liability to Driver
PA for paid driver
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 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)
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
Cars and Rs.1 Lakh in the case of Motorized Two Wheelers)
P A cover for unnamed Persons/Pillion
/ unnamed passengers
Add on Cover
Nil Depreciation
Courtesy Car
Medical Expenses
Personal Effects
Other Details
Whether use of vehicle is limited to own premises Yes/No
Whether the vehicle belongs to foreign embassy Yes/No
Whether the Car is certified as Vintage Car Yes/No
Whether the vehicle is designed for use of
blind/handicapped persons
Yes/No If yes, please specify the
details of Endorsement by RTA
Whether the vehicle is used for Driving Tuitions Yes/No
Whether extension of Geographical Area is required Nepal Bangaladesh,Bhutan,Maldives,
Pakistan,SriLanka
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..
SIGNATURE OF THE PROPOSER
Place :
Date :