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LoanA'lc No-
ApplicationNo.
Employe Code-
EranchCode-
wtr[ YouALrfAYs
Fos Code
PROPOSER'SDETAILS
1.
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Branch :
oate
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o c c u p a t iIo In ,I l I I | | | | i I I I I I I i I I I i I I | ,
Addressforcommunicatr*-,1
I | | i I I I I I | | i I I I I i ! | I I
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City:
District:
State:
Pin
Tel: (O):
(B):
Mobile:
E-mail:
c . d cI , l l l i l i l l
il
Producerc.d"'l
i I | | I I I
P r e m i u m , it " Ii I I I I I
cash/cheque
I I I I I I I I
o a t e al .:' - i = i : . ; 1
: ir-.:.1: l. : i i l
Bank :
Producer's Signature :
DETAILSOFPROPERTY
TO BECOVERED:
Address of the property to be covered (Pleaseprovide only if this is different from the address for communicationf*:
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i I I I I i | | I I I I I i I I r llllt
City:
District:
Name 6 Address of the Financier/ Mortgagee:
6,
7.
8.
9.
ilil|||l
||IIIIIIIi |||IrIrI||r||I||
Pincode*:i
i I I I I I | | | | I
State:
Would you like to delete following covers from the basic cover?
a. Flood, Cyclone group of perils o Yes d No b. Rio! Strike 6 Malicious Damage o Yes d No
Would you like to cover terrorism (only if Riot, Strike etc. evcr is optedl* o Yes d No
Would you like to cover Earthquake(Fire & Shock) : dYes o No
Would you like to opt any other Add-on Covers (give details) :
13.
Would you like to cover Plinth6 Foundationalong with your building : o Yes e No
Age of Building*: Less than 5 years
o 5-10 years
o 10-20 yoars
o Above 20 years
Basis proposed for insurance
a. o Market Values Basis
b. o ReinvestmentValues Basis
Whether you have insured the same property with any other lnsurance Company with the same type of coverage (give details) :
14.
Whether Insurancewas declined by any other Company or imposed any special conditions (give details):
15.
Sum Insured requiredr: (For Bldg. please indicate the present day cost of Construction. Land value is not covered)
Sr.No.
Items
Sum lnsured
Pr!mium
ir.to
Itcms
Sum lnsurud
10.
11.
12,
1.
2.
Building
4.
Prcmium
Plinth6 Foundation
Contents
c.
Others
Add-on Cover
6.
Total
16. Period
P e r i oofdInsurance*:
Ionfs u r a n cFrom
e * : __/__
F r o m - - / - -Hrs.
H r sOn
. o n Il *LrlI**la"J
l r , tlf{E
l r , . r l v l ' g l ' i l ' i lr o M i d N i g h t oi *f l = l r * l * l v l ; l i l ' i l
17. Any otheradditionalinformationyou would liketo furnish/disclose:
18. Paymentmadebycash/chequeN...l
| | I I i I | | I I lo"t"alnlili.;lr:l:'lrl'il::lBank-f.'R.l
| | | I I
DECLARATION
| / We hereby declare that the statements made by me / us in this proposal form are true to the best of my / our knowledge and belief and | / We hereby agree that
this declarationshall form the basis of contract between me / us and the Tata AIG General InsuranceCompany Ltd. lf any additions or alterationsare carried out in the
risk proposed after the submission of this proposal form then the same would be conveyed to the Insurer's immediately.
lAfle agree to the Company taking appropriate measures to capture th6 voice log for all such telephonic transaction carried out by me / us as required by the
procedures / regulations internal or external to the Company.
Insured'sPANCardNumber;
lintheabsenceofPANCard,pleasegivedetailsofanyotherauthorizedphotoidentificationcard.
Number:Ll
I I I I I I I I I
Card Type
contractincase|am/havebeenfoundguittybyanycompetentcourloflawunderanyofthstatUes,direct|yorindirctlygoVerningthepreve|ono|mo
Sources of funds (pleasc y' where applicable):
o Salary
e Business
o Other (Please specify)
Premiumpaid by Cash/ChequeNo*.:
Place:
Date:
Amount* (Rs.)
I=|--Ir,:I*rI r | .:Ivi vI
Signature
Model N a m e :
lnsuredtill
INSURANCE
ACT 1938SECTION
4I - PR(IIIBITIONOFREBATES
No person shall allow
lives.or.property in India,any rebate of the whol or part of the commission payableor any rebateof the premium shown on the policy, nor shall any peron ta(ing out or renewin! or
continuing a policy accept any rebate,except such rebate as may be allowed in accordancewith the prospectusor tables of the lhsur6r.