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OFFICE:
BHARTI AXA GENERAL INSURANCE COMPANY LIMITED
PROPOSAL
First Floor, The Ferns Icon, Survey No. 28,
Next to Akme Ballet, Doddanekundi,
Off Outer Ring Road, Bangalore- 560037,
Toll-Free Helpline: 1800-103-2292
E-mail: customer.service@bharti-axagi.co.in
SMS <SERVICE> to 5667700
Website: www.bharti-axagi.co.in
Please fill this form in Block Letters and Tick the Boxes where appropriate FPV
(Please answer all questions completely. This policy commences only after the proposal is accepted and subject to
realisation of premium.)
INTERMEDIARY DETAILS
Name Code
Branch Code
PROPOSER’S DETAILS
Name Mr. / Mrs. / Ms. / Dr. / M/s.
Fax No.
Address
Details of Electrical Accessories Item Details Make & Model Year of Manf. IDV
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Details of Non-Electrical Accessories Item Details Make & Model Year of Manf. IDV
Are you a member of Automobile Association of India? If Yes, please state Yes No
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Name of Association
Membership No.
Date of Expiry
*In case of wrong declaration of NCB all the benefits under the Motor insurance policy stands forfeited
COVERAGE DETAILS
Voluntary Excess: Do you wish to take Voluntary Excess over and above the Compulsory Excess? Yes No
Private Car None Rs. 2,500 Rs. 5,000 Rs. 7,500 Rs. 15,000
Scooter None Rs. 500 Rs. 750 Rs. 1,000 Rs. 1,500 Rs. 3,000
Do you wish the Geographical Area Extension under your proposed Insurance cover? If Yes, please select the relevant box:
Bangladesh Bhutan Nepal Sri Lanka Maldives Pakistan
Do you require Unnamed PA Cover: Yes No If Yes: No. of Passengers
Sum Insured per Person
Do you require Named PA Cover: Yes No
If Yes: Name i) Sum Insured i)
ii) Sum Insured ii)
iii) Sum Insured iii)
iv) Sum Insured iv)
Do you wish to cover Legal Liability to:
a) Driver Yes No c) Other Employees Yes No
b) Unnamed Passengers Yes No d) Soldier/Sailor/Airman employed as a Driver Yes No
Do you wish to restrict the legal liability towards Third Party Property Damage? Yes No
DETAILS OF HIRE PURCHASE / HYPOTHECATION / LEASE
Please state if the vehicle is under: Hire Purchase Lease Agreement Hypothecation
If so, give name and address of concerned parties:
Full Name M/s.
Address
DRIVER DETAILS
Does the owner have a valid driving license? Yes No
PAYMENT DETAILS
Kindly select one Cheque D.D./P.O. Credit Card Cash
Cheque/D.D./P.O. no. Dated
Bank Name
Credit Card no. Master Visa
Expiry Date Premium Amount Rs.
In words
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DECLARATION
I / We hereby declare that the statements, answers given by me / us in this proposal form are true to the best of my knowledge and belief. It is hereby understood and
agreed that the statements, answers and particulars provided herein above are the basis on which this insurance is being granted and that if, after the insurance is
effected, it is found that any of the statements, answers or particulars are incorrect or untrue in any respect, the Company shall have no liability under this insurance.
I / We agree and undertake to convey to Bharti AXA General Insurance Company Limited any change / alterations carried out in the risk proposed for insurance after
submission of this proposal form.
I/We hereby declare that all the damages observed at the time of inspection of the vehicle shall not be claimed by me/ us from Bharti AXA General Insurance Co. Ltd.
Date: