Regd. & Head Office: 3, Middleton Street, Kolkata Proposal form for National Insurance Sampoorna Suraksha Bima

Transcription

1 Regd. & Head Office: 3, Middleton Street, Kolkata Policy Issuing Office: Proposal form for National Insurance Sampoorna Suraksha Bima For Office use only: Policy Nos.... Premium..Risk Date. Time Receipt Nos.. Agency Code Please read the prospectus carefully before completing this form. All questions should be answered in full. Ticks or dashes will not suffice unless otherwise mentioned. Suppression or nondisclosure of any material information will make the insurance void. A. GENERAL INFORMATION 1. Full name of the Proposer : 2. Business/Occupation : 3. Address : Place of Business / Occupation A) For Communication 4. Telephone Nos. Office Residence 5. Fax 6. Date of birth : Age in completed years : 7. Sex - Male/ Female 8. Average monthly income 9. Income Tax PAN 10. Details of existing insurance with our Company 11. Period of Insurance : From.To SECTIONS CHOSEN (Please tick) Section- I is Compulsory. Besides, minimum two more sections from the six optional Sections are to be taken. Section I : Personal Effects of the proposer and family members staying with Him/Her against Fire & Allied perils, Earthquake, Burglary and Theft, Specified home appliances against Breakdown, Televisions against breakdown, accidental damage & TPL and Jewellery & valuables against All risks Section II : Residential building (Fire & Allied perils, Earthquake) Section III : Personal Accident (For the proposer & named family members) Section IV : Mediclaim Insurance (For the proposer & named family members) Section V : Professional Indemnity (For the proposer) Section VI : Personal Computer ( Of the proposer & / or his family members installed in the residence) Section VII : Private Car/ Motor Cycle owned by proposer (Package cover)

2 DETAILS TO BE COMPLETED IN RESPECT OF THE SECTIONS CHOSEN SECTION I : Please read the Prospectus and choose the appropriate Plan. 1. Please tick the Plan chosen and cross out the others. PLAN A. Do you require for Terrorism? : Yes / No 2. The complete address of the RESIDENTIAL PREMISES the contents of which are to be insured under the chosen plan. SECTION II - RESIDENTIAL BUILDING (ADDRESS OF WHICH IS GIVEN IN SECTION-I ABOVE) NB: Construction of the Building Pucca only. (Kutcha building as per Fire Tariff are not covered) (i) (ii) Reinstatement Value of the Residential Building / Flat to be insured excluding plinth and foundation. Do you require for Terrorism? : Yes / No Rs. SECTION III : PERSONAL ACCIDENT Details of the Persons to be covered. (Proposer, Spouse, eligible dependant children) i. Amount to be insured for in Rupees Lakhs: Please tick the appropriate box. a) Proposer b) Spouse (If earning) c) Spouse (if not earning) 50% of the CSI (Proposer) or Rs2 lacs whichever is lower d) Children 25% of the CSI or Rs1 lac whichever is lower(per child) Insured Name Age Existing Infirmity/ Disability if any Risk Type Name Of Assignee Relation ship with the Proposer Proposer CSI C B earned Spouse Child Child ASSIGNMENT CLAUSE FOR PERSONAL ACCIDENT INSURANCE I.do hereby assign the money payable in the event of my death by National Insurance Company Limited to Shri./Smt.. my.and I further declare that his/her receipt shall be sufficient discharge to the Company. I further declare that in the event of death of the Assignee named herein all benefits shall become payable to the children named in the policy and I further declare that his/her/their receipt shall sufficient discharge to the Company. Place :-.. Date :- Signature of the Proposer Assignment witness by Sl.NO. Name Address Signature

3 Section- IV : MEDICLAIM INSURANCE (modified) Details of the Persons to be covered. (Proposer, Spouse, parents residing with the Proposer) eligible dependant children and Dependant Sr No 1 Name Sex Date of Birth. Relationship with Proposer Sum Insured (to be in multiples of Rs. 50,000/- to max. Rs 5 lacs) Cumulative Bonus earned If other family members residing with the proposer (i.e Spouse, eligible dependant children and dependant parents) are required to be covered, separate Insured Person details form should be completed for each of such family members. INSURED PERSON S DETAILS (FOR THE PROPOSER) To be completed separately including Questionnaire Form for each insured person (if more than one Insured Person is required to be covered please obtain additional forms from the Company). 1) Profession/Occupation/Trade or Business ( Please describe fully with nature of duties) : 2) Name and address of your Family/ usual Medical Practitioner, his qualifications : And Tele No. State/ Union Territory : Medical Practitioner s Regn. No. : 3) Are you at present or any other time in the past covered under any other Insurance Type (PA, Cancer Insurance, Hospitalisation Insurance or other Medical Insurance). If so, give particulars of - : Insurer, policy no. and period of Cover : Claim Amt. Received / receivable : Period : From To 4) Any Proposal for this Insurance or any other similar insurance refused or cancelled or higher premium charged. If so, give details.: MEDICAL HISTORY TO BE COMPLETED BY THE PROPOSER/INSURED PERSON. PLEASE ANSWER THE FOLLOWING QUESTIONS IN YES OR NO (A DASH IS NOT SUFFICIENT) AND GIVE FULL DETAILS, IF ANSWER IS YES : i. Are you in good health and free from physical and mental disease or infirmity or medical complaints? If not in good health give full details. ii. Have you ever suffered from any diseases/illness? If yes, give details including clinic/hospital where Treatment taken and duration of treatment. NOTE : If you had ever suffered from Diabetes or Hypertension, please complete the additional Questionnaire for Diabetes & /or Hypertension below.

4 iii. a. Have you ever suffered from dental problems? b. If yes, specify the same c. When were you treated last for the same. iii. Give particulars in table below of any other illness or diseases or accident or operation sustained by you in the past. Nature of illness/disease/ Date first Name of attending Whether fully Injury and treatment received treated medical practitioner recovered. Is Surgeon with his treatment Address and continuing Telephone Number iv. Are there any additional facts affecting the proposed Insurance which should be disclosed to Insurer? v. Please give details of any knowledge of any positive existence or presence of any ailment, sickness or injury which may require medical attention TO BE COMPLETED BY PROPOSER IN CASE OF ADVERSE HISTORY IN THE PROPOSAL FORM IN RESPECT OF APPLILCABLE ILLNESS DIABETES QUESTIONNAIRE 1. Date of diagnosis of Diabetes : Did you suffer from coma or procoma? : Do you take any anti-diabetic drugs? If so, please give names with dose. 4. Please give details of Fasting and Prostprandial Blood Sugar Readings, E.C.G. findings and Other investigation reports with dates. Please : also send reports. 5. Do you suffer or have suffered from any complications of diabetes or any other diseases? : HYPERTENSION QUESTIONNAIRE 1. What is your Blood pressure reading, please state with dates? : Please state names of anti-hypertensive drugs with dose : Are you a smoker? : Is it Essential/Secondary/malignant Hypertension? : Please state whether you have suffered from any complications Or other diseases : Please give findings of all investigation reports : SECTION V: PROFESSIONAL INDEMNITY (for the Insured) Cover available if the Proposer is a Professional of any of the following categories. Professionals - Doctors, Engineers, Architects, Interior decorators, Chartered Accountants, Financial Consultants, Management Consultants, Lawyers, Advocates, Solicitors, Counsels. 1. Profession in respect of which insurance required. 2 Professional Qualification 3 How long in practice 4 Specializations 5 Business address or address of the place of profession, firm/hospital

5 6 If profession is as a joint venture or partner of any firm, the name of such firm/joint venture and proposer s share in such business. 7. No.of qualified (in your profession) persons working with you. 8. No. of unqualified (i n your profession) persons working with you (e.g. Clerks) 9 Annual fees(average Of previous 3 years or projected whichever is higher) Applicable for Architects, Engineers, and Interior Decorators 10. Has any claim being made upon you or legal proceedings instituted or likely to be instituted 11. Limit of Indemnity required Any One Occurrence/Any One Period, i.e., the Amount to be insured against (between Rs.1,00,000 to Rs.10,00,000) in Rupees Lakhs SECTION VI : PERSONAL COMPUTER (while installed in the residential premises mentioned under Section I above) Item No. Description of items Year of mfg. Remarks Replacement value Rs. (Please give full and exact description of all equipments, including name of manufacturer, type, serial number, voltage, power input, etc.). (Give particulars of any part of equipment to be insured which has had a breakdown or failure during the last three years and shows any signs of disrepair.). (Please state current cost of replacing the equipment by new equipment of the same kind + freight charges, custom duties, costs of erection, package material SECTION VII - PRIVATE CARS / MOTORISED TWO WHEELERS PACKAGE THE VEHICLE CAN BE INSURED ONLY IF THE PROPOSER IS THE REGISTERED OWNER 1. Registration No. and Date of Registration of the Vehicle: 2. Registering Authority & Location : 3. Year of Manufacture : 4. Engine No : 5. Chassis No. : 6. Make of Vehicle : 7. Type of Body/Model :

6 8. Cubic Capacity : 9. Seating capacity including Driver : 10. Whether the vehicle is driven by non-conventional source of power If yes, please give details. 11. Whether the vehicle is used for driving tuitions. 12. Whether extension of geographical area to the following countries required? Bangladesh, Bhutan, Maldives, Nepal. Pakistan and Sri Lanka. If Yes state the name of the countries. 13. Whether use of vehicle is limited to own premises? 14. Whether vehicle is used for Commercial purposes? 15. Whether vehicle belongs to foreign embassy / consulate? 16. Whether the car is certified as Vintage car by Vintage and Classic Car Club of India? 17. Whether vehicle is designed for use of Blind/ Handicapped/ mentally challenged persons and duly endorsed as such by RTA? 18. Whether the vehicle is fitted with fibre glass tank? 19. Do you wish to opt for higher deductible over and above the compulsory deductible (Rs.50 for Two Wheelers and Rs.500/Rs.1000/- for Private Cars) If yes, please specify the amount (for two wheelers) Rs.500/750/1000/1500/3000 (for private cars) Rs.2500/5000/7500/ Are you a member of Automobile Association of India? If yes, please state a. Name of Association b. Membership No. c. Date of expiry 21. Are you entitled to No Claim Bonus? If yes, please submit proof thereof. 22. Is the vehicle fitted with the any Anti-theft device approved by the AARI.? If Yes, attach Certificate of Installation in the vehicle issued by Automobile Association of India. 23. Liability to Third Parties. The policy provides Third Party Property Damage( TPPD )of Rs.1 lakh/-(two wheelers) and Rs.7.5 lakhs (Private Cars ). Do you wish to restrict the above limits to the statutory TPPD Liability limit of Rs.6000/- only?: 24. Do you wish to cover Legal Liability to? A) Driver (No. of persons ) B) Other employees (No. of persons ) C) Unnamed Passengers (No.of Persons )

7 25. Do you wish to include Personal Accident (P.A.) Cover for Named persons? If yes, give name and Capital Sum Insured (CSI) opted for. The maximum CSI available per person is Rs. 2 lakhs in the case of Private cars and Rs. 1 Lakh in the case of Motorised two wheelers. Name CSI opted (Rs.) 26. Do you wish to include P.A. Cover for unnamed persons/ hirer/pillion passengers(two wheelers)? If yes, give the number of persons and Capital Sum Insured (CSI) opted. The maximum CSI available per person is Rs. 2 lakhs in the case of Private cars and Rs. 1 lakh in the case of Motorised two wheelers. Number of persons CSI opted (Rs.) 27. Insured s Declared Value (Please fill up the following table:) Insured s Declared Value of vehicle Non - electrical accessories fitted to the vehicle Electrical & electronic accessories fitted to the vehicle Side Car (two wheeler) Trailer (Pvt.cars) Value of CNG / LPG Kit Rs. Rs. Rs. Rs. Rs. Rs. Total Value DECLARATION I do hereby declare that the above statements and answers are true and that I have not withheld any information whatsoever regarding the proposal. I hereby declare that all statutory provisions relating to my/our business proposed for insurance are complied with. I agree that this proposal and declaration shall be the basis of the contract between me and National Insurance Company Limited whose policy for the insurance proposed is acceptable to me. I undertake to exercise all ordinary and reasonable precautions for safety of the property as if it were uninsured. 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 Date : SIGNATURE OF PROPOSER CERTIFICATE ( TO BE SIGNED BY PROPOSER IF PROPOSAL FORM IS NOT FILLED IN BY HIM / HER) I herby declare and agree that the entire contents of this Proposal form and related documents has been fully explained to me and I have fully understood the significance of the proposed contract; and accordingly only I have signed this proposal form and declaration as above. Date : PROHIBITION OF REBATES SIGNATURE OF PROPOSER 1. No person shall allow 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 or renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the prospectus or tables of the Insurers. 2. Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.