PROPOSAL FORM - MOTOR INSURANCE

1. RC copy
Pls attach to email
2. Previous Insurance certificate
KINDLY WRITE ALL INFORMATION IN CAPITAL LETTERS

First Name
Last Name

Complete Communication Address

(incl. City)
Client Details

State
Pincode
Phone number (mobile)
Emergency phone number
Email id
Gender
Date of Birth
Marital Status
Occupation

Make of vehicle
Model & variant of vehicle
Date of first registration
RTO
Vehicle Details

Year Of Manufacture
Vehicle registration number
Engine number
Chassis number
Cubic Capacity (cc)
Seating Capacity
Color of the vehicle
Fuel Type

Existing insurance company

Existing policy number

Existing Policy Details

Existing policy start date

Existing policy end date
NCB in existing policy (%)
Did you make a claim in existing
policy?
Total amount of claims in existing
policy
 Existing P
Number of claims lodged in existing
policy

Name of nominee
Nominee
details Age of nominee
Relationship with nominee
Hypothecation

Is the vehicle under Hire Purchase /

Finance / Lease Agreement /
details

Hypothecation?

Name of bank or financing institution

Since how long are you driving a

vehicle
No. of people who can drive in your
Driving Details

family
Parking type at night
Annual kms driven in your vehicle
(apprx)
Age of youngest driver in your family

Do you have a driver?

Transaction reference number

Payment
details

Date of transaction

Amount of premium paid (Rs.)

Comments
(if any)

I / We hereby declare that the statements, answers given by me / us in this proposal form are true to the best
It is hereby understood and agreed that the statements, answers and particulars provided herein above are th
insurance is being granted and that if, after the insurance is effected, it is found that any of the statements, an
Declaration

incorrect or untrue in any respect, the Company shall have no liability under this insurance.

I / We agree and undertake to convey to Bharti AXA General Insurance Company Limited any change / altera
proposed for insurance after submission of this proposal form.

I/We hereby declare that all the damages observed at the time of inspection of the vehicle shall not be claime
General Insurance Co. Ltd.

FOR OFFICE USE ONLY

 FOR OFFICE USE ONLY

Inspection Agency Name

applicable)
Inspection
Details (if
Inspection Reference Number
Vehicle

Inspection Date
Inspection time
Inspection Status

Agent Name
Intermediary
Details

Agent Code

Agent Staff code

Insurance
Proposed
Period of

Policy Start Date (DD-MM-YYYY)

Policy End Date (DD-MM-YYYY)

R INSURANCE

urance certificate
N CAPITAL LETTERS

Pls check in RC book

Pls check in RC book

e.g. HYUNDAI
e.g. SANTRO ZIP LXI 1.2
2005 Pls check in RC book
Pls check in RC book
2005 Pls check in RC book
Pls check in RC book
Pls check in RC book
Pls check in RC book
Pls check in RC book
Pls check in RC book
Pls check in RC book
Pls check in RC book

Pls check existing policy

Pls check existing policy
2013 Pls check existing policy
2014 Pls check existing policy
Pls check existing policy

Yes or No

Pls check your claim experience

 Pls check your claim experience

Age should be 18 years or over

Yes or No

Multiple choice

Multiple choice
Multiple choice

Multiple choice

Yes or No

Payment ref. no/ Cheque no.

2015

me / us in this proposal form are true to the best of my knowledge and belief.
ers and particulars provided herein above are the basis on which this
fected, it is found that any of the statements, answers or particulars are
liability under this insurance.

nsurance Company Limited any change / alterations carried out in the risk

e of inspection of the vehicle shall not be claimed by me/ us from Bharti AXA

E ONLY
E ONLY

Pls check inspection report

Pls check inspection report

2014 Pls check inspection report
Pls check inspection report
Recommended or decline

2015

2016
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2013 2011
2014 2012 JAN MALE

2015 2013 FEB FEMALE

2014 MAR YES
2015 APR NO
MAY 0 to 1 year
JUN 1 to 2 years
JUL 2 to 3 years
AUG 3 to 5 years
SEP More than 5 years
OCT
NOV
DEC Less than 2500
2500 to 5000
5000 to 10000
10000 to 25000
Over 25000 kms
MARRIED

UNMARRIED

1
2
3 or more
Covered
Open(Road Side)
Open(Inside Compound)
Recommended
Decline