Bajaj-Allianz Motor Insurance Proposal-Form Page 3
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4Have You or any of the above drivers:
a) Been prosecuted or convicted for any offence or any prosecution pending?
Yes
No
b) Had motor insurance refused, had a policy cancelled or had any special conditions imposed by any motor insurer?
Yes
No
c) Had any loss, accident or claim during the last 3 years in connection with any motor vehicle?
Yes
No
If you have answered Yes to any of questions above please give details _________________________________________________________________
Proposed Coverage
34)
Insured Declared
Non-Electrical
Electrical and
Trailer
Value of
Total Value
Value of the vehicle
Accessories fitted
electronic accessories
CNG/LPG kit
to the vehicle
fitted to the vehicle
(Rs.)
(Rs.)
(Rs.)
(Rs.)
(Rs.)
(Rs.)
35) Type of cover required: Package/ Third Party/any other (please explain)
36) Do You wish to limit Third Party Property Damage cover to the statutory limit of Rs.6000
Yes
No
37) Do You wish to opt for legal liability to :
(a) Paid Driver: Yes/ No; (b) Other employees: Yes/ No (if Yes, No. of persons
)
38) Do You wish to opt for Personal Accident cover for named persons?
Yes
No
If Yes, please give the name of the persons (other than Yourself or paid driver /cleaner)
39) Do You wish to opt for Personal Accident cover for unnamed passengers?
Yes
No
If Yes, No. of persons
Sum Insured per person
40) *What is the deductible You wish to opt for?
(a) Minimum Deductible (as per tariff)
(b) Rs. 2500 + minimum deductible
(c) Rs. 5000 + minimum deductible
(d) Rs. 7500 + minimum deductible
(e) Rs. 15000 + minimum deductible
41) Whether geographical area extension to the following countries is required?
Bangladesh,
Bhutan,
Maldives,
Nepal,
Pakistan,
Srilanka (please tick whichever applicable)
Payment Details:
Cheque
Cheque No:
Cheque Date:
Cash
Credit Card
Others ____________
42) Documents attached:
Cover Note
Renewal Notice
Policy Copy
Inspection Report
Registration Certificate
Declaration
43) Premium Calculation Table
IDV (Insured Declared Value)
Value of Electrical Accessories
Value of CNG/LPG
Value of Non-Electrical Accessories
Own Damage
Amount
Liability
Amount
Own Damage @_________%
Basic TP Cover
CNG/LPG
CNG/LPG
Electrical/Non-Electical Accessories
PA for Owner Driver
(-) NCB @_______%
PA for Passengers
(-) TPPD Restriction
LL for Paid Driver
(-) Voluntary Excess of Rs._________
(-) Automobile Association Discount
(-) Discount for ATD
(-) Commercial Discount
TOTAL
Gross Premium (Own Damage + Liability)
Service tax @
Net Premium
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