NATIONAL INSURANCE COMPANY LIMITED (Subsidiary of General Insurance Corporation of India) Regd. Office : 3, Middleton Street, Calcutta – 700 071.

Address of the Policy Issuing Office

PROPOSAL FORM FOR MOTOR CYCLE / SCOOTER INSURANCE NOTE

For Office use only

1.

Policy No. ................................................................

2.

3.

All questions should be answered in full. Ticks or dashes will not suffice. Acceptance of this Proposal is subject to the rules and regulations of the Indian Motor Tariff and no liability is undertaken until the proposal has been accepted by the Company and the premium paid. The term Motor Cycle will include Motor Scooter and/or Auto Cycle.

1.

Full name of the Registered Owner of the Motor Cycle / Scooter (Proposer) :

2.

Business / Occupation :

3.

Address of the Proposer :

Premium Rs. ............................................................ Risk Date ........................... Time ........................... Receipt No ............................................................. Agency Code .........................................................

Place of Business / Occupation

4.

For Communication

Purpose for which the Motor Cycle will be used :

________________________________________________________________________________________________ 5.

Particulars of the Motor Cycle proposed for Insurance :

Registered Mark & Numbers

Make & Type of Body

Chassis No.

Engine No.

Cubic Capacity

Year of Manufacture

Seating capacity of the Side Car, if attached

6.

Full Address of the Registration Authorities

7.

Please State the Type of Cover required (delete which is not applicable) Act Liability only

8.

Extended Act Liability plus Fire and/or Theft cover

Extended Act Liability plus Own Damage

Particulars of the existing / previous policy covering the Motor Cycle proposed for insurance (not necessary in case of a new Motor Cycle)

Name and Address of the Policy Issuing Office

9.

Extended Act Liability i.e. Third Party

Policy Number

Period of Insurance

Type of Cover

Claims lodged during the preceeding 3 years Year

No.

Amount

Period of Insurance From ......................................... / To ............................................ (Please refer Note 2 above)

________________________________________________________________________________________________ THE FOLLOWING QUESTIONS ARE TO BE ANSWERED, IF COVER MORE THAN ‘ACT LIABILITY OR EXTENDED ACT LIABILITY ‘ IS REQUIRED. ________________________________________________________________________________________________ 10. If any Financing Institution / or any other person is interested in the Motor Cycle proposed for insurance, please give the name and address of the same. Under Hire Purchase Agreement

Under Lease Agreement

Under Hypothecation Agreement

11. In respect of the Proposer & the Motor Cycle proposed for insurance has, any Insurance Company ever : Declined Proposal

Cancelled & refused to renew the policy

Required an increased Premium

Imposed special condition or excess

YES / NO

YES / NO

YES / NO

YES / NO

12. The Motor Cycle will be driven by (delete which is not applicable)

The owner

Any particular person

Any Person

13. Does the owner or that person who will drive a) Suffer from defective vision or hearing or from any physical infirmity ?

YES / NO

b) Have you ever been convicted in the past for causing accident ?

YES / NO

14. Please state the following a)

Estimated present value of the Motor Cycle

Rs.

Side Car if any

Rs.

Rs.

b)

Estimated value of non-electrical items like neckrest, sunvisor etc. Fitted to the Car

Rs.

c)

Does the Proposer wish to opt out any of the extraneous perils ?

i)

Riot, Strike & the Terrorist activity

Yes / No

ii)

Earthquake (fire & shock damage)

Yes / No

Rs.

iii)

Flood, Typhoon, Hurricane, Storm, Inundation, Cyclone, Hailstorm

Yes / No

d)

Does the Proposer wish to bear the first of each and every claim for loss of or damage to the Motor Cycle ? (Please strike out which is not applicable)

Yes / No

Rs. 100 e)

Rs. 200

Is the proposer (if an individual) a member of any recognised Automobile Association in India ? If yes, please state

Name of the Association

f)

Membership No.

YES / NO

Date of Expiry

Is the Proposer , from the Previous Insurer, i) Entitled to a No Claim Discount ii) Subject to malus ? Premium for own damage

Yes ..................% No Yes ................% No Total

Rs.

Premium Computation for Office use only

15. a) Does the proposer wish to insure for Personal Accident Benefits in respect of ? Owner of Car ( if an individual) YES / NO

Named or unnamed Pillion rider

Sum Insured Rs.

YES / NO

In case of named Pillion riders please state Name of the Pillion rider

b)

Age

Does the proposer wish to insure the Operator/Cleaner against wider legal liability? Yes

No. of persons

No.

THE FOLLOWING QUESTION IS REQUIRED TO BE ANSWERED, IF THE COVER IS REQUIRED NOT BY AN INDIVIDUAL ________________________________________________________________________________________________ 16. Please give the address where the Motor Cycle will usually be garaged after the business hours ________________________________________________________________________________________________ 17.

Whether the owner of the Motor Cycle is :

i)

a Private Limited Company or a Public Sector Undertaking or a Statutory Body with a paid up capital of Rs. 10 lacs or above.

YES / NO

ii)

a Co-operative Society with a paid up capital of Rs. 5 lacs or above.

YES / NO

iii) a Charitable Trust whose income is exempted from Income Tax.

YES / NO

________________________________________________________________________________________________ In case of payments by cheque, please state Cheque No. ..................................... .............. date ......................................... .......drawn on ......................................................... for Rs. .............................. ________________________________________________________________________________________________

Declaration I/We desire to insure with NATIONAL INSURANCE COMPANY LIMITED, in respect of the Motor Cycle described above hereby warrant that the Statements and Particulars given above are true, and I/We have not suppressed, misrepresented or mis-stated any material fact. I/We agree that this Proposal and declaration shall be held to be promissory and shall be the basis of the contract between me/us and National Insurance Company Limited, and agree to accept the Company’s usual form of Policy for insurance of this nature. I/We undertake that the Motor Cycle to be insured shall not be driven by any person who to my / our knowledge has been refused any Motor / Vehicle Insurance or continuance thereof. Date ............................ Signature of the Owner of the Motor Cycle ________________________________________________________________________________________________

Seal & Signature of Bank / Financing Institution and date

Name and Signature of the person completing this Proposal if it differs from the Proposer

Name & Signature of Agent / Inspector

Agent Code No.

Skd./ motor cycle