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Commercial Vehicle Proposal Form

Commercial Vehicle Proposal

Details of Proposer
Choose if you are an Individual or Corporate.
- Individual
- Corporate
Full Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region Country
Phone*
Email
PAN No.*
Occupation*
Have you taken loan for this vehicle ?
- Yes
- No
State the name of the Bank/ Finance Co. Interest*
Is the vehicle owner other than Proposer*
- Yes
- No
Detail of Vehicle Owner
Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region Country
Phone*
Email
Period of Insurance from
Date Format: MM slash DD slash YYYY
Period of Insurance to
Date Format: MM slash DD slash YYYY
Details of proposed private car:
Engine No.*
Year of Manufacture*
Please enter a number from 1970 to 2021.
Date of Registration*
Chassis No.*
Make
Date of Purchase
Date Format: YYYY dash MM dash DD
Registration Number
Model
Purchased
- Old
- New
Type
CC
Goods Carrying Capacity in Tons
Value Without Accessories
Value With Accessories
Total Declared Value*
State what type of cover is required ?*
- Comprehensive
- Third Party
- Third Party Fire
- Third Party Theft
- Third Party Theft & Fire
Do you wish to cover Riot & Strike/ Terrosrism risks?*
- Yes
- No
Do you wan to bear "Voluntary Excess" in case of claim? If so, please mention the amount.
- Rs. 1,000
- Rs. 2,000
- Rs. 5,000
- Rs. 10,000
Following rate of discount are provided in the amount: 1. Rs. 1,000 = 10% 2. Rs. 2,000 = 15% 3. Rs. 5,000 = 20% 4. Rs. 10,000 = 25%
Please pick for which purpose the vehicle is used?
Mention*
Is there double wheels and spring at back side of vehicle?
- Yes
- No
Please mention the Geographical territories for the vehicle use.
Please mention the place/ garage where you usually park.*
Where do you park your vehicle?*
- Garage
- Open Place
Will the proposed vehicle be periodically mainatained?
- Yes
- No
Is your proposed vehicle insured in any Insurance Co.?
- Yes
- No
Mention the name of Insurance Co. and expiry date.*
Are you entitled for No Claim Discount (NCD) ?*
- Yes
- No
Please enclose Renewal Notice indicating NCD.
Accepted file types: jpg, pdf, jpeg, png.
Has any Company or Insurer
Rejected your propose?
- Yes
- No
Increased premium or imposed special condition?
- Yes
- No
Cancelled your Policy or rejected to renew?
- Yes
- No
Is there any accident or loss in three years?
- First Choice
- Second Choice
Do you have your other vehicles insured in this company?
- Yes
- No
Please upload the copy of the policy.
Accepted file types: jpg, png, pdf.
Do you wish to insure accidental insurance?*
- Yes
- No
a) Driver
b) Conductor
c) Helper
c) Others (Nos. and details)
Please mention the No. of passenger for accidental insurance. The No. should be limit according to vehicle's seat capacity.*
Consent*
I hereby declare that the above statements are true and that I have withheld no information which might influence the acceptance of this proposal. I agree that this proposal shall be the basis of the contract between me and the Company and deemed to be incorporated in the Policy.

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