THE NEW INDIA ASSURANCE COMPANY LIMITED
Registered & Head Office- 87, M.G. Road, Fort, Mumbai-400001
RAJRAJESHWARI MAHILA KALYAN BIMA YOJANA (NEW)

PROPOSAL FORM

1. Name of the proposer :
2. Address :
3. Age (Completed years) :
4. Occupation :
5. (a) Marital Status
(b) Name and age of the husband
(if applicable)
6. Cover required (Please specify
Whether basic or basic with
Extended cover)
7. Nomination details Witness to nomination
Name 1. Name & Address with signature
Address
Relationship with
Proposer
1. Policy Period (1 year to 5 years)
2. Period of Insurance : From : _____________ To : ______________
DECLARATIONS
1. EXISTING DISABILITY : I hereby declare that I do / do not suffer from loss / disablement /
incapacity of _______________ and I understand that the Company shall not pay for the same
in the event of any accidental injury.
2. I declare that the questions were explained to me fully by Shri / Smt. / Kumari
and that the answers thereto have been recorded by him / her under my dictation and that I have
affixed my signature / thumb impression after satisfying myself that they have been correctly
recorded.
Date : Signature / Thumb Impression of Proposer
DECLARATIONS
I declare that I have explained the questions to the Proposer, that the Proposer’s answers thereto have
been recorded by me and that he / she has affixed his / her signature thumb impression after satisfying
himself / herself that the answers have been correctly recorded.
Date : Signature of person writing the answers
I / We, hereby declare that the information furnished above are true and correct to my / our knowledge
and belief.
Place : Date : Signature of the Proposer
NOTICE :
Maximum amount receivable :
Attention is drawn to Condition No.6 of the Policy when the Insured is having more than one
Rajrajeshwari Mahila Kalyan Bima Yojna in force at the time of the accident or injury.
Renewal of the Policy after expiry :
It will be necessary for the Insured to contact the nearest Office and obtain a fresh insurance after the
expiry of the Policy as renewal notice or intimation will not be sent by the Office.
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 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 /BROKERCOLLECTION
/ SCROLL NO POLICY NO.
.