PROPOSAL FORM FOR MOTOR PRIVATE CARS/JEEPS INSURANCE
Please answer all questions. Benefits under the policy may not be payable in the event of non-disclosure or misrepresentation of material facts. If you are in doubt as to whether any fact is material please disclose same. Tick boxes (√) where appropriate
Token Number          
If you have already filled Form 1 and did not submit details, enter the token number you received.

1. Proposer
* 1.1 Name in full (Rev. / Mr. /Mrs. /Miss. /Dr.)
:
* 1.2 Postal address
:
* 1.3 Telephone No.
:
*1.4 E-mail Address
:
1.5 Business / Occupation
:
1.6 Address where the vehicle is usually
      garaged
:
* 1.7.1 : NIC No.
:
* 1.7.2 Years of driving experience
:
2. The Vehicle
* 2.1 Registration No.
:
* 2.2 Make :
2.2.1 Model :
* 2.3. Year of Manufacture
:
* 2.4 Chassis No. :
* 2.5 Engine No.
:
* 2.6 Cubic / Cylinder Capacity
:
2.7 Seating Capacity (including driver)
:
2.8 Details of accessories (other than factory-fitted) you have installed in the vehicle:
i. Description
:
ii. Value
:
Rs.
* 2.9 Value for Insurance
     (including accessories)
:
Rs.
The proposed value above should be the present market value of the vehicle.
* 2.10 Was the vehicle imported 'Duty Free' or at Concessionary Duty :
Yes
No
If Yes, Value
:
Rs.
* 2.11 Type
:
Saloon
Station wagon
SUV/HRV
Dual Purpose
Other (Please specify)
2.12 Is the vehicle modified/altered from the original manufacturer’s specifications:
Yes
No
If "Yes", please give complete details
:
  
3. Ownership
* 3.1 Are you the registered owner
:
Yes
No
If "No", Name of Registered Owner
:
3.2 Name of the Institution who has financial          interest
:
4. Usage of Vehicle
      Private use: social, domestic, leisure       purposes only.
:
Yes
No
      and business or employment purposes
:
Yes
No
      Other - Please specify
:
5. Drivers
* 5.1 Vehicle is driven by
:
Self
Spouse
Named Driver
Any Licensed Driver
* 5.2 Have you or anyone detailed to drive this vehicle been refused, had the vehicle
       insurance cancelled or special terms imposed by any insurer ?
Yes
No
* 5.3 Have you or any other driver had any motor accident in the past three years?
Yes
No
        If "Yes" please fill the below table with required details
Year
Name of Driver
Details of accident
Claimed Amount (Rs.)
6. Details of Cover Required
* 6.1 Cover Required
:
Comprehensive
Third party, Fire & Theft
Third Party only
* 6.2 Period of Insurance
:
From
:
To
:
7. Rebates
7.1 If you are a member of the Automobile Association, please indicate number and expiry date
:
7.2 Do you wish to bear first portion of an Accident Claim?
      Other vehicles
:
Rs. 2,000/-
Rs. 5,000/-
Rs. 10,000/-
Rs. 20,000
* 7.3 If you are entitled to a ‘No Claim Discount’, please state the number of years
:
       Previous Insurer / Policy No
:
8. Additional Covers for Comprehensive Insurance, Please mark (√) your choices
(a) Damage to your vehicle caused by : Strike, Riot and Civil Commotion
Yes
No
(b) Damage to your vehicle caused by : Terrorism
Yes
No
(c) Damage to your vehicle caused by : Natural Perils (Flood, Storm, Earthquake)
Yes
No
(d) Special Windscreen Cover / window breakage cover without affecting NCB
Yes
No
(e) Enhanced Towing Charges (Maximum Rs.10, 000.00)
Yes
No
Rs.
(f) Learner Driver Cover
:
Name:
Date of Birth   :  
(g) Personal Accident Benefits for the following (Amount Rs. 15,000/- to Rs. 500,000/-)
•   Proposer / Spouse
Yes
No
Rs:
•   Paid Driver
Yes
No
Rs:
•   Driver and All Passengers
Yes
No
Rs:
Extensions
:
WCI – Driver
Yes
No
Strike, Riot and Civil Commotion
Yes
No
(i) Other please specify
:
Please check your answers carefully before signing the declaration below.
Declaration

I / We want to effect the insurance specified here and I / We
  • declare that all the answers given in this Proposal are in every respect true and correct.
  • agree that this Proposal and Declaration shall be basis of the Contract of Insurance between me / us and People’s Insurance Limited.
  • understand this application will be subject to the approval of People’s Insurance Limited and the premium fully paid and received by the Company before cover is effected.
Proposer's Signature
Date :
I hereby agree that the entered details are correct
This document is not a contract of insurance. Please refer to the policy (which will be issued upon acceptance of your application) for applicable terms, conditions and exclusions.