PROPOSAL FORM - MOTOR INSURANCE
(Private Cars I Motorized 2 wheelers I Motorised 3 wh passenger carrying for pvt purpose)

For office use
Type of Cover OLiability Only Cover DPackage Cover Oothers, PI. specify Issuing office BO/Do
Period of Insurance: From To Direct/Agent/ Do/ Broker/ Dealer ___ rn rn I I I I I CD rn I I I I I Special Client Code
1. Personal Information Pre-Inspection by
Dtd.~~ ___ Time ----
Name:
(First) (Middlel (Last) Computation of premium
Address I I I
I I I
I I I
State Pin Code.
Mobile No. I I I I I I I I I I I Email
Tel No. (Resi) : LLU I I I I I I I I I Date of Birth CD rn I I I I I Payable Amt. : Rs.
Payment mode : Cash/ Cheque/ BG/CD/Cr.CARD
PAN No. I I I I I I I I I I I Qualification. Marital Status 0 Cover Note No. dtd.
{"if married) Proposal Accepted/ Not Accepted
Occupation Gender MOF 0 Annual Income
Personal Accident Cover to Individual Registered Owner -Driver. CD
cover available for one vehicle only if Owner-Driver holds a valid Dl) Authorised Person/ UW with date & time
Manufacturer
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2. Vebide Info•.•••atioo
Make Model of Body
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Year of Mfg 1_1_1 __
Date of Regn I~~I_~I__ ~ _
Cubic Capacity
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SEATING CAPACITY
(Including driver) o::J
LLU LlJ LlJ
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Insured Declared Value·
Non-Electrical
Value of Vehicle (lDV) (3= Electrical & Electronic Side Car {Two-
Value of CNG/ Total Value (including all
Accessories fitted to the Accessoriesfitted to the wheeler) Trailer
of the Vehicle (1)
Vehicle (2)
1+2) Vehicle (4) (Pvt Cars) (5)
LPG kit (6) extra fittings) (7=3+4+5+6)
Rs. Rs. As. Rs. As. Rs. Rs.
FUEL TYPE OPetrol oDiesel OLPG OCNG OBi-fuel
If Bi-fuel, then specify if fitted separately by other than Manufacturer
Petrol/Diesel & LPG/CNG oBattery OOthers. Please specify _ CD (Please note that RC has to be endorsed for Bi-fuel Kit)
1. Is vehicle designed for use of blind/physically
challenged persons & RC accordingly endorsed 7
3. Is the vehide fitted with any anti-theft device?
(If yes, attach certificate of installation issued by AAI)
s. Whether you intend to opt for higher deductible over and above the compulsory deductible? (Rs. 50 for 2 wheelers & Rs. 1000 for private cars)
(Option for higher deductible entitles you to a discount on Premium)
If yes, specify amount Rs.________ {2- Wheelers As. SOO/7S0/1000/1500/3000 OR Pvt. Cars: 2500/5000/7500/1S000
6. Are you a member of Automobile Association of India (Discount on 00 Premium: 5% max. Rs. 200)
Name of Association Membership Number
I I I I I I I I I I I I I I
Date of Expiry IDD/MM/YV)
I I I I I I I I
rn
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7. The policy provides Third Party Property Damage {TPPDI of Rs. 7.5 Lakhs {Pvt carsl and Rs. 1 Lakh (2-wheelersl
o you wish to opt for statutory TPPD coverage of Rs. 6,000 only? IDiscount on TP premium: As. 100/- for pvt. Car & As. 50/- for 3Wh & 2 Whl
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6. legal liability: Indicate the number of employees
for whom you intend to cover legal liability
Driver/ Conductor/ Cleaner
Other Employees
Daangladesh Oahutan OMaldives ONepal OPakistan Osri Lanka
If so, please mark v to required country name
a.Whether you intend to cover risk of Theft of accessories permanently fined to 2wheeler proposed hereabove (applicable only for two wheeler)?
9. Optional Personal accident cover for unnamed persons· : 00 you wish to include following PA (Personal Accident) Coverages:
CD
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No. of Persons
No. of Paid Drivers
(51opted for per person: Rs.
CSI opted for per person: Rs.
10. 0 tional Personal accident cover for named
Name Sh/Smt
CSIopted for. Rs.
-(cover is available only for passengers limited to registered carrying capacity. )
ersons· : In case of named persons, give name and (51 0 ted for:
Sh/Smt
Rs.
OIC La"'st Add-on Co>·crs IT] b. Do you require Alternate Car Benefits?
If yes, please indicate the number of days CD 0 5 010 015
(Incaseof anaccidentItheft of the imuredvehicle,the insuredwill beprovided
reimbursementfor useof alternatevehiclefor limitedperiodof time)Terms&
COnditionsapply
If renewal, whether previous policy has Nil Depreciation Cover?
(Please attach a proof thereof)
(Alternate policy option for the insured whereby deprecIation is not deducted
from the claim at the time of settlement of loss)Terms & Conditions apply
c.Do you require the cover for loss of Personal Effects? (Only for Pvt Car)
If yes, please indicate the insurance limit
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ORs.5000 oRs.10000
" S. Driver Details '\
Name of Driver Age Relationship with
Occupation Does driver suffer from Details of accidents where driver has been involved
proposer
Business/professiooapl/vt Defective Vision: V/N
company/govtemployee/ Defective hearing: V/N
retired/ student Physicalinfirmity:V/N
Business/professionapl!vt Defective Vision: V/N
company/govtemployee/ Defective hearing: V/N
retired/student Physicalinfirmity:Y/N
6. PreriouAl History of the web.ide
2. Whether New or Second Hand rn
4.ls the vehicle in a good road worthy condition and free from damage? cr=J If No, please give details _
6.Policy No.
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a.Expiry
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10. Has any insurance company ever declined/ cancelled/ refused to fenew/ imposed special conditions? cr=J
If yes, please mention the reasons and details thereof _
7.A.ny other relevant information:
Declaration
I hereby declare that the statements made by me in this proposal form are true to the best of my knowledge and belief and I hereby agree that this declaration shall
form the basis of the contract between me and Oriental Insurance Co. ltd. I hereby confirm and declare that above mentioned identification details of my Vehicle No.
______ are correct. Nothing has been hiddenl undisclosed. I declare that the rate of NCB stated above by me is correct and that no claim has arisen in the
expiring policy (copy of the policy enclosed), I further undertake that, if this declaration is found to be incorrect, all benefits under the policy will stand forfeited. I
further understand and agree that Oriental Insurance Company will seek confirmation of above stated details from my previous insurer. Pending receipt of necessary
confirmation, I agree that, though coverage under the policy will be available to me, Oriental Insurance Company will be liable to release the payment towards any
claims of the policy onlv after a confirmation in this regard is received.
Further, any survey arranged/allowed by Oriental Insurance Company of the motor vehicle, pending confirmation of this declaration from my previous insurer, shall be
without prejudice to any of the rights and remedies available to Oriental Insurance Company as contained herein and under the relevant laws and regulations. I also
declare that if any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the insurers immediately.
explicitly agree to receive a one page motor policy and give my consent hereby.
Date
Section 41 of Insurance Act, 1938 - Prohibition of Rebates
Nopersonshallallowor offerto alloweitherdirectlyor indirectlyasaninducemento anypersonto takeout or renewor continueanInsuranceinrespectof anykindof riskrelatingto livesor propertyin India,any
rebateofwholeor partof thecommiSSionpayableor anyrebateof the premiumshownon the policy,nor shallanypersontakingout or renewingor continuingapolicyacceptanyrebateasmaybeallowedin
accordancewith the publishedprospecbJses or tablesof the Insurer.Anypersonmakingdefault," complyingwith the provisionsof thissectionshallbepunishablewith fine,whichmayextendto Five HundredRupees.