National Insurance Company Limited
(Subsidiary of General Insurance Corpn. of India)
Regd. Office : 3, Middleton Street, Calcutta – 700071

RAJRAJESHWARI MAHILA KALYAN BIMA YOJANA (NEW)
PROPOSAL FORM

(Important : The company will not be on risk until the Proposal has been accepted by
the Company and the premium paid in full.)
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 2. Name & Address with signature
8. Policy Period (1 Year to 5 Years)
9.Period of Insurance : From ______________ To _____________
10. Declarations
I declare that I have explained the 1. EXISTING DISABILITY : I declare
questions to the Proposer, that the that I do/do not suffer from loss/dis-
Proposer’s answers thereto have ablement/incapacity of ……………..
been recorded by me and that he/she and I understand that the Company
has affixed his/her signature/thumb shall not pay for the same in the event
impression after satisfying himself/herself of any accidental injury.
that the answers have been correctly
recorded.
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.
Signature of person writing the answers Date
Date Signature/Thumb Impression of Proposer:
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
PROHIBITION OF REBATES
The following is an extract of Section 41 of Insurance Act 1938
1. 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 or 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 rebate as may be allowed in
accordance
with the prospectus or tables of the Insurers.
2. Any person making default in complying with the provisions of this section shall
be
punishable with fine which may extend to one hundred rupees.
NOTICE
Maximum amount receivable :
Attention is drawn to Condition No.6 above when the Insured is having more
than one Rajrajeshwari Mahila Kalyan Bime Yojana 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 inimation
will not be sent by the Office.