NOTE: Insured should insist for motor passbook and insurance taken from the policy issuing office after the proposal is accepted. THE ORIENTAL INSURANCE COMPANY LIMITED (Incorporated in India subsidiary of General Insurance Corporation of India) Reg. Office: oriental house, P.B. No. 7037, A-25/27, Asaf Ali Road, New Delhi- 110 002. PROPOSAL FORM FOR MOTOR POLICY FOR CARS USED SOLELY FOR PRIVATE OR PROFESSIONAL PURPOSES Name of proposer (in full) (a) Permanent residential address (b) Permanent business/occupation address Occupation Particulars of car to be insured: Vehicle Regn.No. Make of Car Engine/Chassis No. Cubic capacity Type of body Year of manufacture Seating capacity including driver Date of purchase Purchase price Rs. I.E.V. excluding accessories 1. Do you wish to insure loss of or damage to extra fitting such as : (a) Neck-rest, sunshade, sun-visor or any other non-electronic items fitted to the vehicle. (b) Tape recorder, airconditioner, fan or musical horn fitted in the vehicle? If so, state the make, year of manufacture and estimated value of each item separately. Name & address of registration and taxation authorities: 2. Are you the owner of the car and is it registered in your name? 3. (a) Will the car be used solely for private/professional purposes? If not, state for what other purposes it will be used? (b) Will the car be used for carrying your own goods? 4. Do you desire "A" policy (Act only liability cover) or "B" policy (Act only liability plus loss of damage to car from perils specifically covered by the policy issued after acceptance of proposal. 5. Will the car be driven regularly be any one other than purpose? If so please supply the following information:- Name & occupation of such person(s) Age (s) Period of driving experience Has any company or underwriter at normal rates and terms refused any such person insurance? 6.To the best of your knowledge and belief, do you, or does any other person who to your knowledge will drive, suffer from defective vision or hearing or form any physical infirmity? 7.Have, you or has any other person who to your knowledge will drive, been convicted of any offence in connection with the driving of motor vehicle? 8. Insert total number of vehicles owned and particulars of all accidents or losses during the past three years in connection with all motor vehicles owned o driven by you. Year Total No. Total No. of Owned by of vehicle Accidents proposer 19 19 19 19 19 19 Total Amount of claim Damage to proposers Third Party Others Vehicles No. Amount No. Amount No. Amount 9. Are you now or have you been insured in respect of any motor vehicle? If so, please state name of insurers. 10. Has any insures ever (a) Declined your proposal (b) Required an increased Premium or imposed special condition including excess? (c) Cancelled or refused to renew your policy? 11. Are you entitled to a "No claim" Bonus from your previous insurers in respect of any of the cars described in the proposal? If so, attach renewal notice/ motor passbook. 12. Are you willing to bear a portion of all claims in respect of loss of damage to the vehicle? If so, state amounts Rs. 13. Are you a member of any Automobile Association? If so, state which No. 14. Do you desire to cover accidents to the following persons? (a) Insured if so, state age physical defect, if any (b) Insurer's wife if so, state age physical defect, if any (c) Fore one or more Named person if so, state names 1. 2. 3. Age physical defects, if any If on un-named basis state the total nos., Death and disablement cover or capital sum insured of persons between Rs. 10,000/- to Rs. 2 lacs in multipliers of Rs. 10,000/- Note: 1. That the automatic cover under the policy is for Rs. 20,000/- to cover under the owner/driver of the vehicle. 2. For additional coverage upto a maximum S.I. of Rs. 2,00,000/- premium rates as specified in the Tariff will be charged i.e. @ Rs. 7.50 per Rs. 10,000/- for 2 wheelers and Rs. 5.00 per 10,000/- four wheelers. 15. Do you desire to have personal accident cover for named/unnamed occupants of the vehicle (including/excluding drivers/other occupant)? If so, give detail of sum to be insured: 16. Do you wise to cover wider legal liability (i.e. both for W.C. liability and legal liability) to your paid driver an additional premium Rs. 15/- 17. Do you desire legal liability cover for maximum Rs. 1 lac in respect of employees of insured travelling in car No/Yes Additional premium Rs. 20/- per employee 18. Do you wise to cover increased TP property damage cover (other than goods carried in the car) 1. From Rs. 6,000/- to 50,000/- additional premium Rs. 15/- 2. Increase from Rs. 50,000/- Rs. 1 lac additional premium Rs. 25/- 3. For each slab of Rs. 50,000/- Rs. 1 lac additional premium Rs. 15/- 4. Unlimited Rs. 50/- 19. (i) Do you wish that cover against risk of riot and strike be excluded? (If excluded, a discount of 0.15% on I.E.V. is allowed on the premium) (ii) do you wish that cover against risk of flood etc. be excluded? (If excluded, a discount of 0.10% on I.E.V. is allowed on the premium) (iii) Do you wish that cover against risk of earthquake etc. be excluded? (If excluded, a discount of 0.10% on I.E.V. is allowed on the premium). Period of Insurance, From to To, The Oriental Insurance Company Limited I/we hereby declare that the particulars stated above are true I/We agree that declaration and the answers given above shall be the basis of contract between me/us and the company. Date Proposer's Signature The liability of the company does not commence until the company has formally intimated the acceptance of the proposal. PROHIBITION OF REBATES Section 41 of the Indian insurance act, 1938 which is in force the first July, 1939 reads as follows: (1)No person shall 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 India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out of renewing of continuing a policy accept any rebate except such rebate as may be allowed in accordance with published Prospectus or tables of the insurer. (2) Any person making default in complying with the provision of this section shall be punishable which may extend to five hundred rupees. The offer, payment, as acceptance of a rebate of premium hereunder is therefore, a breach of the law.