PROPOSAL FORM FOR TWO WHEELERS/PRIVATE CAR/COMMERCIAL/MISC. & SPL.
TYPE OF VEHICLES

PACKAGE POLICY
(The queries made/details stated below are the minimum requirements to be furnished by a Proposer.The Insurer may seek any other information as desired for underwriting purpose.)

1. Insured Details:- Dev. Officer Name & Code * Agency Code Name *
Proposer's (Owner’s) Full Name: Male / Female Occupation:
Date of Birth Nationality: Tel. No : Mobile No.:
E-Mail Address: Fax No: PAN No.:
Address ( where vehicle is normally kept and used): Address (Permanent)
____________________________________________ ____________________________________________ __________________________ Pin______________ _____________________________________ _____________________________________ ____________________ Pin______________
Period proposed for insurance From:______AM / PM of _____________ to Mid Night of ___________
2.    Particulars of the vehicle:
2.1 - Date of Purchase of Vehicle by Proposer 2.3 - Is Vehicle New or Second Hand at the time of purchase? New/Second Hand
2.2 - Vehicle Used for Private,Social, domestic,pleasure, professional purpose Yes/No 2.4 - Is vehicle in good condition? Yes/No
Give Vehicle Details
2.5 - Type of Vehicle(2 W/Pvt Car /Comm.) 2.6 - Current Ownership
2.7 - New Vehicle Yes/No 2.8 -Year of Manufacture
2.9 - Date of Purchase 2.12 -Color of Vehicle
2.10 - Registration No. 2.11 - Date of Registration
2.13 - Engine No 2.14 - Chassis No
2.15 - Make 2.16 - Model
2.17 - Type Of Body 2.18 - Variant
2.19 - Vehicle Zone : A/B/C 2.20 - Type of Fuel(Petrol/CNG/LPG/Bi-fuel)
2.21 - Whether vehicle is used for driving tuition Yes/No 2.22 -Vehicle use is limited to own premises Yes/No
2.23 - Whether vehicle belongs to foreign embassy or consulate or Imported vehicle without Custom Duty Yes/No 2.24 - Whether vehicle is certified as Vintage car by Vintage and Classic Car Club of India Yes/No
2.25 - Vehicle designed for Blind/Handicapped/Mentally Challenged persons and endorsed by RTA Yes/No
2.26 - Fibre Glass Tank Fitted Yes/No If Yes then Value of Fibre glass fuel tanks
2.27 - Are you a member of Automobile Association of India Yes/No If Yes then Name of Association
Membership No Date of Expiry
2.28 - Car in roadworthy condition and free from damage Yes/No Details of Vehicle Condition
2.29 - Is the vehicle fitted with Anti-theft device Yes/No Give, details - Type / Model
2.30 - Obsolete Vehicle Yes/No
2.31 - Extension of Geographical Area required Yes/No If yes: Extension to: 1. Bangladesh 2. Bhutan 3. Nepal,4 Pakistan 5 Srilanka 6. Maldives
2.32 - Vehicle Invoice Value Rs. 2.32(i) - Body Building Cost Rs.
2.33 - Registration validity date
2.34 - Vehicle Requisitioned by Government Vehicle Requisitioned by Government Yes/No 2.35 - Insured's Declared Value (IDV) Rs.
2.36 - Whether Rally extension required for Motor Racing / Speed Test No.of days for Rally
2.37 - Name and Address of Registration Authority Name and Address of Registration Authority 2.38 -Seating Capacity
2.39 - Cubic Capacity
2.40 - Whether trailer attached to the vehicle (For Commercial Vehicle) Yes/No If Yes then
Number of Trailers Attached
Total IDV of the Trailer Attached
Is the vehicle proposed for insurance Under Hire Purchase / Under Lease Agreement / Under Hypothication Agreement. Yes/No If Yes, give name and address of concerned parties : ________________________________________________________________________________________________________________________
N.B. * For Office Use Only