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

RAJRAJESWARI MAHILA KALYAN BIMA YOJANA 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 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): _____________ year(s)

9. Period of Insurance: From ________________ to ____________________________

10. DECLARATION:
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.
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.

________________________________

Signature of person writing the answers Signature/thumb Impression of Proposer

Date: Date:

I/We, hereby declare that the information furnished above are true and correct to my/our knowledge and belief.

Place: ___________ ______________________________

Date: ____________ Signature of 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 in the policy; nor shall any person taking out or renewing continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses of rebates of the Insurer.
2. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.

NOTICE:
Maximum amount receivable:
Attention is drawn to Condition No. 6 above when the Insured is having more than one Rajrajeswari Mahila Kalyan Bima 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 intimation will not be sent by the office.