THE NEW INDIA ASURANCE COMPANY LIMITED
Regd. & Head Office : New India Assurance Bldg.,87,M.G. Road,Fort,Mumbai–400 001

Proposal Form for Pravasi Bhartiya Bima Yojana Policy

ELIGIBILITY :

This Insurance is specially designed for Indian citizens between the age group of 18 years to 60 years and going abroad for the purpose of employment for the period of their stay abroad on valid visa.

IMPORTANT NOTICE :

This Proposal Form must be completed and signed to the best of the proposer’s knowledge and belief and all material facts* must he disclosed.

• A material fact is one of that is likely to influence the acceptance or assessment of the Proposal.
• Non-disclosure of facts material to the assessment of the risk, providing misleading information, fraud or non-cooperation by the insured will nullify the cover under the policy issued.

1.0 PERSONAL DETAILS :

1.1 Name(Mr/Mrs/Miss): ___________________________________________________
(BLOCK LETTERS)

1.2 Father/Spouse’s Name : _________________________________________________

1.3 Sex : Male / Female : _______________

1.4 Date of Birth : _____ / _____ / ________ Age_____________________________
DD MM YYYY
1.5 Height : ______ ft. _______ inch (________cms.) Weight : ______lbs _____(Kgs.)

1.6 Passport No. : _________________________________________________________

1.7 a) Date of Issue : ____/____/_____ b) Place of Issue : ________________________
DD MM YYYY
1.8 Type of Visa Held:_____________________________________________________

1.9 Address of the proposer in India : _________________________________________

Pin Code : _____________________ Tel. No. : ____________________

1.10 a) Details of Spouse and / or children of the Proposer (maximum two) :

Name Age / Date of Birth Relationship
Spouse
1st Child
2nd Child

b) Address : ______________________________________________________________

______________________________________________ Tel. No. : _______________

2.0 Country of Employment:_________________________________________________

2.1 Address in Country of Employment ________________________________________

_____________________________________________________________________

__________________________________ Tel. No. : __________________________

2.2 Name & Address of work place the proposer is attending : ___________________ Tel. No. ___________________

3.0 a) Brief details of employment to be undertaken: ____________________________

____________________________________________________________________

______________________ Tel. No. : _____________________________________

b) Period of Contract From _______________________ to __________________________
(note: please attach attested copy of the appointment letter of overseas employer)

3.1 Name & Address of Overseas Employer / Sponsor : ______________________________

___________________________________________________________________________

Relationship : ____________________________

4.0 Period of Insurance Required : ____________________________________________

4.1 Commencement Date : _________ / __________ / ______________
DD MM YYYY

5.0 PROPOSER’S MEDICAL HISTORY :

ANSWERS TO THE FOLLOWING QUESTIONS ARE TO BE GIVEN AS YES OR NO (A DASH IS NOT SUFFICIENT)

5.1 Is the proposer in good health and free from physical defect or infirmity ? ___________________

5.2 Does the proposer ordinarily enjoy good health ?
________________________________

5.3 Are there any additional facts affecting the proposed insurance which should be disclosed to insurers ? ________________________________________________________

6.0 Please attach a copy of the Medical Report of the Proposer, if any, which was required for Entry Visa.

7.0 DECLARATION :

I hereby declare that the above answers are true to the best of my knowledge and belief that I have disclosed all particulars affecting the assessment of the risk. I agree that this PROPOSAL and DECLARATION shall be the basis of the contract between me and the Company.

Date : _____ / _____ / ________
DD MM YYYY Signature of Proposer____________________

Place : _____________

8.0 ASSIGNMENT :

I, ______________________________________________ do hereby assign the moneys payable by The New India Assurance Company Limited, in the event of my death to Mr./Mrs. (Name) _____________________________________________ (relation to the
insured) ________________________________ and I further declare that in the event of death of the Assignee named herein all benefits shall become payable to the children named in the Policy and I further declare that his / her / their receipt shall be sufficient discharge to the Company.

Date : _____ / _____ / ________
DD MM YYYY Signature of Proposer____________________

Place : _____________

UNDERTAKING

I, Mr/ Mrs/ Miss______________________________________ do hereby solemnly declare and state that all information given above are true and correct to the best of my knowledge. In case any such information is found at any time in future to be false or misleading or it is found by the insurer that I have not disclosed any fact which is material to the assessment of the risk, the insurance cover granted to me shall be deemed to be null and void and I shall not be entitled to any benefit thereunder.

Date : ____ / _____ / _______ Signature of Proposer_____________________
DD MM YYYY

Place : __________________

PROHIBITION OF REBATES

Section 41 of the Insurance Act, 1938 :

(1) No person shall allow, or offer to allow, either directly or indirectly as an inducement of 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 or part of the commission payable or any rebate of the premium shown on this policy, nor shall any person taking out or renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.

(2) Any person making default in complying with the provisions of this section shall be punishable with fine which may extend upto five hundred rupees.