[ ince Ton ) oe Motor Proposal Form for Private Car / Two Wheeler mest Kae Dear Customer, Thank you fr applying tol TGI's AUTO PROTECTOR. To help us process your policy quickly, plbase ile form completely. While al his i part of our everyday business, we aITGI take special caro safeguard every bit o information you provide us, Tha’ xml because we respect yout ight to privacy, With us, your information I in scfe hands. Our personel willconstonly be in iuch wih you- updating every single deal you provide cbout youre, IF you have any queries, plate cll our Customer Cora Cones at 1800-109-5499 (Toll F We ere commited to bringing you the bes through ITGI's products ond nsved Dotale Nome: ‘Nome ofthe Nanings forthe pupowe of Peroral Accident cover fx owner, diver und Sacton Ti [Correspondence Address: leiy Baie Pin code bile No Whore the vehicle is normaly kept and used i Same as tha of above Yea] /No[_] #1 No, then please mention the location of he vehicle eddess below lAdcress [cay Sa Pin code Maile No Ie he vehicle proposed for inaurance unde Hie Purchese/lacxe Agioerens/Hypothecaton Yes] /Ne[_] _Ploase monk the ype of oproomen! IF Yo, give the nome ond address of he nsivion having rancialneestin the vehi . oy ony Polo T thei? Ey Type of Policy Lik ony Poey Peckage Foley eS Vehicle Details Registration Number | Yeor of Mi Make Model] Colour GC] SeehCap el | Engine Nomber | _Chonls Nomber Dive Tncured's declared val Traed's Declared Non Eleecal cial accesories]. Side corwo Whosle/ | Vale oF CNG/IG Ki Teicha Vee sccetorios “roller [or Rs fs a fe fs Re 'Note: The Insts Declare vole (DV] ofthe vahicle willbe doomed to be he ‘Sum nse! for the purpose ofthis tif and i willbe Fixed of he commencement each policy prid foreach insured vohcl ad it willbe he purpose of Tal Lose/Constucve Tl Loss clans. ‘Addltional information: 1 Whores the vehicle potted at igh? tacked ercsure[/_] i, Not in locked enclosure but win th boundory wal] i. uid he bowndory well 2. Ave you ented No Clam bonus ves Nol] ves % lotoch pro) 2. sth vhil fied with An The Doves ves no 4. Do you with ind Personal Acident (PA) cone for Named Parton ves No IFYes, give the name and Capital Sum Insured (CSI opted for. The Maximum CSI available por person is Rs. 2 lakhs in case of Private car and Rs 1 leks in cose cof Motaresed Two Wheler 5.Ne Rane Roninese Steptoe) 5. Do you wish to inch PA cover for unnamed persons /hiter/pilion passengeralor Two Wheeler) Yes No I yes, give he number of persons and Capital Sum Insured lols in coo of Motoresed Two Whelan No of persons CSI Opted R51 SI opted. The Maximum CSI avilable por person is Rs. 2 ls in case of Private car and Rs. 16.Da you wish to cover Lage Liability to 9. Driver Yer ol b. Enployoes Yor Nol 7.De you wish to opt or higher deductible over and above the compulsory deductible Yes Nol (RS. 100/- For Two wheeler and Rs. 1000/2. 2000 for Private Cr) IFYes, please spocty ho omount, For Two Wheeler Rs. 500/750/1000/1500/3000. Rs For Private Ca 8, 2500/5000/7500/15000 Re 8. Are you a mamber of Avtomebila Association of India? Yes No IF Yer, Phase sate, Nome of Association, Membership No Dote of Exary [po/murrery General information: 1. athe vehicle ure for criving ition Yor | 2. Iphe cvs be eened the georopisa area th flowing conte Yor | Bangladesh [_] shuren [_] Motdves [] Nepal [] Pokiston [_] sei tanke 3. letho use ofthe Vehicle limited to own promises? Yor ol 4. Does the vohiclo belong to foreign emibossy/consul® Yor | 5. Isthe vehicle designed for uso of Bind/Handicapped/Mentelly Challonged persons and Yes Nol duly endorsed as by RTA 6. le the vehicle fod wih fibor gloss fork Yor | 7. Whether he vehicle was New or Second hand a the tne of purchase Now| Second Hand 8. Name and address ofthe Previous Insurer. 9. Previous palcy No. Pered Of Inuranc. To (oo/mnrrry " 0. Pleas give the ders claims ledge during he proceding 3 yoors. (Ary) 5.Na. Year Number ‘AnouiRs) 17. Has any insurance company ever Declined your propos ? Yes] No [7] tyes, Rooton b} Conceled & Refused 1 renew your policy Yer [No [7] tyes, Reoton <) Inposed special condition or excess Yes E] No EE] tyes, Reason 12, Det of river: a) IF you ae individual owner, do hold on eecive diving cense# Yer 1] No [Not Apptcable 8) Age Owner Orver hers «Does the Driver safer from deecive vision or heering or any physee inirmty ves] No yes, Details 4} es the dvr ove’ boon neh convicted for casing any accident or a yes] oO yes, Phose provide he deals os unr ning the ponding prosecutor any Name of Drber Date of Accident Circmslonees of Acide Claim Toa/ Chim RS) 13. Plaate give anyother information that may be relevant. DECARATON (ite oyghe hte sone nate bse sean ea on od cei a ony eel ae hy se et ia etn alo oe pce ee tava aS Ra eS ASA See lay ly ee cea des lens Be ioeac bese wolf ieiomera acho adel Naw Sti fs per hg it ony ed ct pyre oe ean ok dior fai the plead IB Bederarion com Wcreny i play ‘Necseepora ete emehed cle 9 ely oye eon rdw tt Ne Ci CO clowe ne ply bie ‘Ssmaebgegatas neem calender armas te Cin aah ta a a ea oy roe carr econo gene Ni Bp NCB sewed scar ay red weiss no tong ay Eis cera Bis Bed ses Nsom pear eh eels ren ste restart teach Se 2 Re eee, Gerba Pony catravn Sedona Salinas ede an iy oto enantio yee Gea ateh apn Tt. ane toc hob Rea wy? hh ev eae Se 5 aptmaton bali ne oe Grn Boma secret Sf poly" ‘hove NCB wartany wise heen te Bey schdcle abe PROMIION OF REBATES. Seon 41 ofthe Insurance Ae 1938 provides llows No pron dha hier drei noone yop ye ene mane fy kid kia oo ozone ta er ot gt se cee anon tdene my ene ote een es eal et ct et Be ec leeeeth cl yb Ron asl appa ee si Ry ncn Ss lk an he ae BRNLSSTH SRSA a ee ets see ha mele ce Me Nome ard Signe of Fropoer Na & Signo of Avhorizad Ropoerave of TI