Bajaj-Allianz Motor Insurance Proposal-Form (Page 4 of 4) in pdf

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Declaration

I/We, the undersigned hereby declare and warrant that the insurance contract and policy to be issued by Bajaj Allianz General Insurance Company Ltd [Company] is subject

to the declarations, warranties, statements and particulars given in this proposal form. The statements and particulars given in this form are complete, true and accurate to

the best of my/our personal knowledge and belief. I/we have clearly understood the terms and conditions [T & C] to the insurance contract and agree that the statements

and particulars given in this proposal form shall be held to be promissory and shall be the basis of the insurance contract between me/us and the Company and the

Company shall have no liability under the insurance contract if it is found that any of my/our statements or particulars or declarations in this proposal form or other

documents are incorrect and or untrue or suppressed any information or provided misleading or false information in any respect on any matter to the grant of a cover. I/we

will accept the usual T & C and form of the policy prescribed and issued by Company.

I/We hereby agree and undertake that I/we are agreeable to receive one page policy document without enclosing the T & C of policy and I hereby authorise company that

all T & C of policy can be displayed in the website of company. The salient features of the policy, terms and conditions of this proposal have been explained to me/us in

vernacular language, and I/we agree to the same.

ADDITIONAL DECLARATION TO BE GIVEN BY CUSTOMER SEEKING NO CLAIM BONUS:

I/We declare that the rate of NCB claimed by me/ us is correct & that no claim has arisen in the expiring policy period. I/We further undertake that if this declaration is found

to be incorrect, all benefits under the policy will stand forfeited. I/We declare that to the best of my personal knowledge and belief that the vehicle is in sound and

roadworthy condition. I/We undertake that the vehicle to be insured shall not be driven by any person who to my/our knowledge has been refused insurance or

continuance thereof.

Place:

Signature of Proposer

Date:

Name and Designation (In case of Corporate)

Section 41 of Insurance Act, 1938

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 published prospectus or tables of the insurer.

Vehicle Inspection Report (for Break-in Insurance/ Roll Over Cases)

Vehicle No.

Chasis No.

Engine No.

Odometer Reading

Colour

Photographs Attached

Yes

Damage Details

Inspected By

Place

Date and Time