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Private Vehicle Insurance Proposal Form

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 Liability, Accidental Insurance to Driver and Passenger
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%
Is the vehicle used for the purpose of personal and entertainment purpose?
- Yes
- No
Is it used for hire and reward? If so, please mention.
Please mention the place/ garage where you usually park?*
Where do you park your vehicle?*
- Garage
- Open Place
Is the proposed vehicle regular used by other person than proposer?*
- Yes
- No
Detail of Vehicle User
Name and Occupation
Age
Driving Period
Is any Insurance Co. has rejected those person's insurance under general tariff and condition?
- Yes
- No
In your knowledge, is there any disability of eye, ear of Driver?
- Yes
- No
Is in your information is the driver accused of any crime?
- 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
Is there any accident or loss in the last three years?
- First Choice
- Second Choice
Has proposer's or any other person's (if any using proposed car), driving license ever been cancelled?
- Yes
- No
Mention the number of seats for accidental insurance
Driver
Insured and Passenger
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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Details of Proposer

Details of proposed private car:

Detail of Vehicle User

Has any Company or Insurer;

Mention the number of seats for accidental insurance