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LoanA'lc No-

ApplicationNo.

Employe Code-

EranchCode-

wtr[ YouALrfAYs

Fos Code

PROPOSAL FORn (STANDAnD flRE AnD SnEC1AL nERTLS pOLtCy)


@ESTDENflAL PREn #S ONLY)
AII mandatory
fralds marked in bold asterisk*
Note: 1. Acceptance of this proposal is subiect to the rules I reguladonsof All India Fire Tariff. 2. The property proposed for insurance is not covered until
the proposal is accepted and premium paid. 3. Applicable only for residential buildings with RCC/RBC/TILES/ACC
roof and external walls of Burnt bricks /
Stone / Concreteblocks. 4. Failureto disclosefacts material to the assessmentof the rGk or providing misleading information may render the contract void.

PROPOSER'SDETAILS

1.

'illlti|]lill

Name of the Proposer*

tii|il1|itiil|

|iltl

FOR PRODUCERSUSE ONLY

liilriilti
|ilriilllt

Branch :

oate
oteirttr.:ir--l*l:,;lril'rl
:'lrl ,.1
i"i,o,,o*" , I il:::.. : :",ili5
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

|iliiliti|lllitiiil||illililill
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*:

lililti

llllllllllllllillililililillill

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

cAR DETAILS:llF YOUoWN A CAR,PLEASE


Make of Car

Model N a m e :

FILq IN THE DETAILS BELOW FOR INFORMATION PURPOSE ONLY}


Yearof manufacture:

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.

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