The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

PROPOSAL FORM FOR PEDAL CYCLE INSURANCE

SCOPE OF THE POLICY

The Insurance covers loss or damage to pedal cycle by any accidental external means or by fire burglary, theft only and also liability to the third parties which the insured may incur in respect of (i) death of or bodily injury to any person (ii) damage to property.
Subject to the conditions, provisions and exceptions as stated in the Policy.

1. Name of Proposer __________________________________________________

2. Occupation _____________________________________________________

3 Address _______________________________________________________

SCHEDULE

4. Description of Pedal Cycle Name of Maker Chasis No. & Model of Pedal Cycle Net Price Paid Date of Purchase

5. Address where the Pedal Cycle is
usually kept
6. For what purpose the cycle will be
used
7. Indicate type of Insurance cover
required
(a) Loss or damage to pedal cycle by any
accidental means or
by fire, burglary, theft only
(b) Legal liability to third parties, if
required, what amount ?

8. Have you ever previously proposed for
pedal cycle insurance? If so, to what
Company and with what result.
9. Has any Company declined to renew
or asked increased terms.
10.Have you ever had any pedal cycle
accidents or sustained loss of or
damage to a pedal cycle by any cause
? If so, give details.
11.Has the risk been previously Insured?
If so,
(a) The Name of Insurance Company
(b) Policy No.___________________
(c) Period _____________________
(d) Rate Charged ______________
(e) Any special terms and conditions
imposed.

I/We agree that this proposal shall be the basis of the contract between the Company and myself/ourselves and I/We undertake to exercise all reasonable precautions to prevent injury, loss or damage.

Date ___________20 Proposer’s Signature _______________

Note 1.The liability of the company does not commence until the proposal has been accepted by the
Company and full premium paid.
2. If space is found insufficient, please attach separate sheets for details.
3. Premium Rates will be quoted on application.
4. Insurance is the subject matter of solicitation.

PROHIBITION OF REBATE -- Section 41 of the Insurance Act 1938
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 part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebates as may be allowed in accordance with the published prospectuses or tables of the Insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to Five Hundred Rupees.

FOR OFFICE USE -
MARKETING / DEVELOPMENT OFFICER'S REPORT
The Proposer is known to me/my agent / Broker for___years and I recommend acceptance of this proposal.

Name and Code No. Signature of Dev. Officer / A/AO-D

ACCEPTED BY DATE & TIME RATE REMARKS
CODES - OFFICE /DEV. OFFICER / AGENT /BROKER-
COLLECTION / SCROLL NO POLICY NO.
.