NATIONAL INSURANCE COMPANY LIMITED (Subsidiary of General Insurance Corporation of India) Regd. Office : 3, Middleton Street, Calcutta
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1 NATIONAL INSURANCE COMPANY LIMITED (Subsidiary of General Insurance Corporation of India) Regd. Office : 3, Middleton Street, Calcutta Address of the Policy Issuing Office PROPOSAL FORM FOR COMMERCIAL VEHICLE INSURANCE NOTE 1. All questions should be answered in full. Ticks or dashes will not suffice. 2. Acceptance of this Proposal is subject to the rules and requlations of the Indian Motor Tariff and no liability is undertaken until the proposal has been accepted by the Company and the premium paid. For Office use only Policy No.... Premium... Risk Date... Time... Receipt No... Agency Code Full name of the Registered Owner of the Motor Vehicle (Proposer) : 2. Business / Occupation : 3. Address of the Proposer : Place of Business / Occupation For Communication 4. Purpose for which the vehicle will be used (delete which is not applicable) Transportation of goods Own goods For public Transportation of Passengers for hire/reward For other purpose (detailed hereunder) 5. Particulars of the Motor vehicle proposed for Insurance Registered Letters & Numbers Make & Type of Body Year of Manufacturer Chassis No. Engine No. Gross Vehicle Weight in Kgs As per Certificate of registration Cubic Capacity Licensed Passenger carrying capacity
2 6. Full Address of the Registration Authorities 7. Please State the Type of Cover required (delete which is not applicable) Act Liability only Extended Act Liability i.e. Third Party Extended Act Liability plus Fire and/or Theft cover Extended Act Liability plus own Damage 8. Particulars of the existing / previous policy covering the vehicle proposed for insurance (not necessary in case of a new vehicle) Name and Address of the policy issuing office Policy Number Period of Insurance Type of Cover Claims lodged during the preceeding 3 years Year No. Amount 9. Period of Insurance From... To... (Please refer Note 2 above) THE FOLLOWING QUESTIONS ARE TO BE ANSWERED, IF COVER MORE THAN ACT LIABILITY OR EXTENDED ACT LIABILITY IS REQUIRED. 10. If any Financing Institution / or any other person is interested in the vehicle proposed for insurance, please give the name and address of the same. Under Hire Purchase Agreement Under Lease Agreement Under Hypothecation Agreement 11. Please state the following Premium Computation for Office use only a) Estimated present value of the vehicle b) Estimated value of non-electrical items like neckrest, sunvisor etc. Fitted to the vehicle c) Estimated value of the electronic / electrical items fitted To the vehicle Tape Recorder Air Conditioner Fan Musical Horn
3 11. Please state the following (Contd.) Premium Computation For Office use only d) Does the Proposer wish to opt out any of the extraneous perils? i) Riot, Strike & the Terrorist activity ii) Earthquake (fire & shock damage) iii) Flood, Typhoon, Hurricane, Storm, Inundation, Cyclone, Hailstorm, Frost e) In case of contract carriage, whether the vehicle shall operate within a radius of 50 kms from the city limits f) Will the vehicle be driven by named driver? If yes, please state the details of the drivers as follows Sl.No. Name Age Driving Licence No. and date of expiry Period of driving experience g) In addition to compulsory excess, does the Proposer wish to bear the first of each and every claim for loss of or damage to the Vehicle? h) Is the Proposer from the Previous Insurer, i) Entitled to a No Claim Discount Yes...% No ii) Subject to malus? Yes...% No Premium for own damage Total 12 a) Does the Proposer desire Additional liability cover for Third Party property damage in excess of 6,000/-? (as is available under the Motor Vehicles Act) Yes / No b) Does the proposer wish to insure the employees against wider legal liability? Yes, No. of Persons... / No c) In respect of goods carrying vehicle, does the Proposer wish to insure in respect of more than six (6) employees? YES, No. of Persons... / No
4 13. Please give the following particulars in respect of the Trailers, if any. a) Maximum number of trailers to be towed at any one time by the towing vehicle b) Total number of trailers to be insured c) Registered Letters & No. d) Licensed goods carrying capacity e) Estimated value for insurance 14. In respect of the Proposer & the vehicle proposed for insurance has, any Insurance Company ever Declined Proposal Cancelled & refused to renew the policy Required an increased premium Imposed special condition or excess YES / NO YES / NO YES / NO YES / NO THE FOLLOWING QUESTION IS REQUIRED TO BE ANSWERED, IF THE COVER IS REQUIRED NOT BY AN INDIVIDUAL 15. Whether the owner sof the Vehicle is : i) a Private Limited Company or a Public Sector Undertaking or a Satutory Body with a paid up capital of 10 lacs or above. YES / NO ii) a Co-operative Society with a paid up capital of 5 lacs or above. YES / NO iii) a Charitable Trust whose income is exempted from Income Tax. YES / NO In case of payments by cheque, please state Cheque No date......drawn on... for...
5 Declaration I/We desire to insure with NATIONAL INSURANCE COMPANY LIMITED, in respect of the vehicle described above thereby warrant that the Statements and Particulars given above are true, and I/We have not suppressed, misrepresented or mis-stated any material fact. I/We agree that this Proposal and declaration shall be held to be promissory and shall be the basis of the contract between me/us and National Insurance Company Limited, and agree to accept the Company s usual form of Policy for insurance of this nature. I/We undertake that the vehicle to be insured shall not be driven by any person who to my / our knowledge has been refused any Motor Vehicle Insurance or continuance thereof. Date... Signature of the Owner of the Vehicle Seal & Signature of Bank / Financing Institution and date Name and Signature of the person completing this Proposal if it differs from the Proposer Name & Signature of Agent / Inspector Agent Code No. Skd./ motor commercial
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