UNITED INDIA INSURANCE CO LTD

Transcription

1 UNED NDA NSURANCE CO LD SANDARD PROPOSAL FOR FOR LABLY ONLY POLCY For Private Cars / wo Wheelers A.Questions that are necessarily to be listed for granting the cover as per the otor Vehicles Act1988. A. Personal Details of Proposer/Owner: 1 Proposer s Owner s Full Name n capital letters 2 Address where the vehicle is normally kept Pe rs on al D et ail s n capital letters, with pin code PN: elephone: Fax: obile No: ail d: 3 Occupation / Business 4 ype of Cover Liability Only Policy 5 Period of nsurance From: Hrs on / / o : Hrs on / / A. Vehicle Details Ve hi cl e Sp ec ifi ca ti on s 6 Registration Number of the Vehicle 7 Date of Registration of the Vehicle 8 Registering Authority & Location 9 Year of anufacture 10 Engine Number 11 Chasis Number 12 ake of the Vehicle 13 odel 14 ype of Body 15 Cubic Capacity of the Vehicle 16 Seating Capacity including driver 17 Whether the vehicle is driven by nonconventional source of power / CNG / LPG / BiFuel? f YES, please give details 18 Whether the use of vehicle is limited to own premises? YES NO 19 Whether the vehicle is used for commercial purpose? YES NO 20 Whether the vehicle is used for driving tuitions? GR44 YES NO 21 Details of Hire Purchase / Hypothecation / Lease 5 a s the vehicle proposed for insurance is: i Under Hire Purchase? ii Under Lease Agreement? iii Under Hypothecation? b f YES, give name and address of concerned party/parties:

2 A. LABLY SECON: COVERAGE 22 Coverage for liability against hird Party Risks Death or Bodily njury required in respect of: i Owner Driver only hird Party Risks: Death / Bodily njury ii Any person other than Paid Driver f YES, give details of such other persons: Note: 1. Section146 of otor Vehicles Act1988 makes it mandatory for the owner of the vehicle to ensure that he or any other person authorized by him to drive a vehicle in public place has insurance against third party risks. he explanation to Section146 exempts the paid driver. 2. As per Section 147 2a he liability is as incurred in the case of death / bodily injury of a third party] hird Party Risks: PPD Do you wish to have the statutory hird Party Property Damage PPD liability of Rs.6000/ only? [For additional PPD limits, please see Q.No.25] hird Party Risks: Liabilit y to 'Work men' under W.C.Ac t1923 Comp ulsoril y to be covere d by.v Act Legal liability to persons employed in connection with operation of the vehicle who are workmen. [he liability of the Employer under the Workmens Compensation Act1923 is covered under the otor Vehicles Act Drivers No.of persons: 2 Employees Workmen No.of persons: Note: he otor Vehicles Act1988 under Sec.1471iii covers liability to employees who are workmen within the meaning of the Workmen s Compensation Act1923. For additional coverage, please refer to Q.No.26]

3 B. Questions that provide additional covers as per Endorsements Addl. PPD Additio nal Liabilit y to Workm en Liabilit y to Employ ees who are not Workm en Person al Accide nt Cover For Owner Driver 25 G R he Policy provides additional hird Party Property Damage liability limits of Rs.1,00,000/ for wo Wheelers and Rs.7,50,000/ for other classes of vehicles. Do you wish to cover the additional limit? [Refer to Q.No.23] Do you wish to cover wider legal liability to employees who are workmen? [his information is sought to cover in addition to liability under the Workmens Compensation Act1923, also liability under the Fatal Accidents Act1855 and the Common Law] Note: he additional liability under Common Law and Fatal Accidents Act in respect of employees who are workmen is covered under this endorsement. [Refer to Q.No.24] Do you wish to cover wider legal liability to employees who are NO workmen? Note: he liability under Common Law and Fatal Accidents Act1855 in respect of employees who are not workmen can be covered under this endorsement. 28 Personal Accident Cover for Owner Driver is compulsory in the Liability Only Cover. Please give details of nomination: a Name of the Nominee & Age : b Relationship : c Name of the Appointee f Nominee is a inor : d Relationship to the Nominee : Note: 1. Personal Accident cover for Owner Driver is compulsory for Sum nsured of Rs.1,00,000/ for wo Wheelers and Rs.2,00,000/ for Private Cars. 2. Compulsory PA cover to owner driver cannot be granted where a vehicle is owned by a company, a partnership firm or a similar body corporate or where the ownerdriver does not hold an effective driving license

4 PA Cover for Name d Occup ants Do you wish to include Personal Accident cover for named persons?, f YES, give name and Capital Sum nsured CS opted for: Name CS Opted Nominee Relationship Rs Note: he maximum CS available per person is Rs.2 Lakhs in case of Private Cars and Rs.1 Lakh in the case of otorized wo Wheelers PA Cover for Un Named Occupa nts Geogra phical Extensi on Do you wish to include Personal Accident cover for Unnamed Passengers/hirer/pillion passengers wo Wheelers? f YES, give number of persons and Capital Sum nsured CS Opted: No. of Persons: C.S. Per Person: Note: he maximum CS available per person is Rs.2 Lakhs in case of Private Cars and Rs.1 Lakh in the case of otorized wo Wheelers Whether extension of geographical area to the following countries required? 1 Bangladesh 2 Bhutan 3 aldives 4 Nepal 5 Pakistan 6 Sri Lanka Note: Presently the territory covered is geographical area of ndia. Extension of geographical area cover can be availed by use of this endorsement C. Questions that are elicited for information and data collection purposes

5 32 Previous History: a. Date of purchase of the vehicle by the Proposer: / / b. Whether the vehicle was new or second hand at the time of purchase? : New / Second Hand c. Will the vehicle be used exclusively for i Private, Social, Domestic, Pleasure & Professional Purpose? ii Carriage of goods other than samples or personal luggage? Previo us History d. s the vehicle is in good condition? f NO, please give details: e. Name and Address of the previous insurance company: f. Previous policy number: g. Period of nsurance : From: o: h. Claims lodged during the preceding 3 years: YEAR NO.OF CLAS CLA AOUN Rs. 33 Details of the Driver: a. Age & Date of Birth of the Owner: Age: Yrs DOB: / / b. Age & Date of Birth of the Driver: Age: Yrs DOB: / / c. Does the driver suffer from defective vision or hearing or any physical infirmity? f YES, please give details of such infirmity: Driver Details d. Has the driver ever been involved / convicted for causing any accident of loss? f YES, give details as under including the pending prosecutions: Driver s Name : Date of Accident: Loss / Cost Rs.: Circumstances of Accident / Loss:

6 Declaration by the nsured /We hereby declare that the statements made by me/us in this Proposal Form are true to the best of my/our knowledge and belief and /We hereby agree that this declaration shall form the basis of the contract between me/us and the United ndia nsurance Company Ltd. /We also declare that any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the nsurance Company immediately. Place: Date : Signature of the Proposer/s. PROHBON OF REBAES nsurance Act1938, Section 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 ndia, 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 of renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the prospectus or tables of the nsurer. 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. Note: Denial of "hird Party Liability Only Cover" by nsurer, for reasons other than fraud/misrepresentation by proposer, will entail Regulatory action.