MOTOR INSURANCE PROPOSAL FORM - TWO WHEELER

Development Officer's Name & Code: P.SURESH / 50724 Broker's / Agent's Code: / 90000425

. .Mr. MIDHUN VARGHESE PAN Number :

Proposer's Name
. .PULIMOOTTIL, VADAVATHOOR P.O, THANNIKKAPADY Dist. : KOTTAYAM, Kerala, KOTTAYAM, KOTTAYAM, Kerala, PIN -
Address for Correspondence
. 686010
.
City : .KOTTAYAM District : .KOTTAYAM
State : .Kerala Pincode: .686010
. .2575810 9446145242 E-mail Address:midhunvar@gmail.com
Telephone, Fax Number & Mobile
Gender : M
.
HPA / Hypothecation
. .Package policy
Type of Policy Required
.
Period of Insurance From 27/02/2017 00:00:00 hours To 26/02/2018 midnight

Details of Vehicle
. . . . . . . .
Reg. No. Engine And Chassis Year of Make & Model / Seating CC/Gross Color Fuel Used
. . . . . .
Number Make Type of Body Capacity Vehicle
. . . . . . .
Weight
. .

.
KL-05-AE-0648
.
486901296 / 8454033 / 2012
. .
Suzuki Access 125 & / Solo
.
2 124
. Black
. .

Registering Authority - Name and location :Civil Station, Collectorate, Kottayam, Kerala
ALL AMOUNTS ARE :
.
Insured Declared Value
. . . . . .
Vehicle Value Electrical /Electronic Non-Electrical Side Car / Trailer LPG / CNG Kit TOTAL Value
. . . . . .
accessories accessories
.
21357
.
0.00
.
0.00
.
0.0
.
0.00/0.00
.
21357.00
. . . . . .
Invoice Value
0.00 0.00 0.00 0.00 0.00/0.00 0.00

HISTORY OF VEHICLE:
. . . . . . .
Previous Policy Type of Cover Name of Insurer Entitlement of Date of Policy Claim Experience Date of First
. . . . . . .
Number & Address Claim Bonus Expiry for Last 3 Years Purchase &
. . . . . . .
Regn.
.
12/02/2012

USAGE OF VEHICLE:
. . . .
Purpose of Use Details of Vehicle Parking Details of Driver Average Km Run in a Year
.Personal . .
. .No
Voluntary Excess : Do you wish to Opt for Voluntary Excess over
.
and above the Compulsory Policy Excess
. .No
Are you a member of Automobile Association of India
. .No
Is the vehicle fitted with the any Anti-Theft Device
.
approved by ARAI
. .
Whether the vehicle is driven by non-conventional source
 MOTOR INSURANCE PROPOSAL FORM - TWO WHEELER

Development Officer's Name & Code: P.SURESH / 50724 Broker's / Agent's Code: / 90000425

. . . .LPG-0.00,CNG-0.00,Fibre Glass Tank-0.00

Whether the vehicle is driven by Bi-fuel kit / Fibre Glass
. . .
Tank Fitted
. .
No
Do you wish to restrict TPPD cover to Statutory limit of 6000 / -only
ADD-ON COVERS REQUIRED
. .No
Theft of Accessories (Two Wheelers Only)
. .IMT39-0,IMT39A-0,IMT37-0,IMT37A-0
Legal Liability to Driver
. .50
PA for paid driver
. .0.0 / person(s)
PA Cover for Named Persons
. .0.0 / 0 person(s)
PA cover for unnamed persons / Pillion / unnamed passengers
. .No
Courtesy Car
. .No
Medical Expenses
. .No
Nil Depreciation
. .None
Personal Effects
Other Details
. .No
Whether use of vehicle is limited to own premises
. .No
Whether the vehicle belongs to foreign embassy
. .No
Whether the Car is certified as Vintage Car
. .No
Whether the vehicle is designed for use of blind / handicapped
persons
. .No
Whether the vehicle is used for Driving Tuitions
. .
Whether extension of Geographical Area is required
. .Yes
Do you wish to have a one page policy ?*
* Note :Policy terms and conditions are as per India Motor Tariff and are displayed at National Insurance Company

DECLARATION BY THE INSURED

I/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 I/We hereby agree that this declaration shall form the basis of the contract between me/us and the National
Insurance Company Ltd.
Blank
I/we 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.
. .
Place Signature of the Proposer
. .

.
Date
.