Bajaj-Allianz Motor Insurance Proposal-Form

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Bajaj Allianz General Insurance Company Limited
Regd. & Head Office : GE Plaza, Airport Road, Yerwada, Pune - 411006.
IMD Code
Sub IMD Code
Local Office Details
IMD Name & Contact No.
LG / Emp. Code
PRIVATE CAR PACKAGE POLICY - PROPOSAL FORM
1.
Please answer all questions in BLOCK letters
2.
The Liability of the Company does not commence until this Proposal has been accepted by the Company and premium has been paid
3.
This Proposal will be the basis of any subsequent policy that we issue to you. It is therefore essential that you provide all the information in this Proposal FULLY AND
ACCURATELY and that you provide us with any and all additional information relevant to risk to be insured or our decision as to acceptance of the risk or the terms upon
which it should be accepted
In case you are/were Insured with us? kindly mention your Customer ID:
Proposer Details
1) Full Name: Title/ First name/ Middle Name/ Surname
2) Gender: Male
Female
3) Date of Birth :
Age (in completed years):
4a) Residence Address:
Address Line 1
Address Line 2
City
State
Pincode
E-Mail
4b) Office Address:
Address Line 1
Address Line 2
City
State
Pincode
5) Mobile
Telephone (Res.)
Telephone (Office)
6) Are You a member of the Customer Loyalty Program? Yes
No
If yes, kindly provide your Customer Loyalty No:
7) Occupation :
(a) Govt. Employee
(b) Defense Personnel
(c) Public sector employee
(d) Private Sector employee
(e) Business
(f) Self Employed (give details
)
(g) Others
8) Proposed Period of Insurance:
From
To
9) Hypothecation Details:
Name of Financial Institution/Bank:
Name of Branch and Branch address:
Loan Account Number:
Vehicle Details
1) Registration No.
Date of Registration
2) Registration Authority
Location of the vehicle
3) Vehicle Registered as: Private Car
Commercial Vehicle
4) Year of Manufacture
5) Date of purchase of the vehicle by You
6) Whether the vehicle was New or Second Hand at the time of purchase
7) Engine no:
Chassis No:
8) Make:
Model :
Subtype
Colour
9) Cubic capacity
Seating capacity: Driver (1) +

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