Bajaj Allianz General Insurance Co. Ltd.

,
Bajaj Allianz House, Airport Road, Yerawada,Pune - 411006. Reg No.: 113
CIN: U66010PN2000PLC015329
UIN : IRDAN113RP0025V01200102
PF000747975

Scrutiny No. Receipt No. Policy No. IMD Code Sub IMD Code IMD Name Mobile No. Emp/LG Code

PRIVATE CAR PACKAGE POLICY - PROPOSAL FORM

1. Please answer all questions in BLOCK letters 2. The Liability of the Company does not commence until this Proposal has been accepted by the Company and
premium has been paid 3. This Proposal will be the basis of any subsequent policy that we issue to you. It is therefore essential that you provide all the information in
this Proposal FULLY AND ACCURATELY and that you provide us with any and all additional information relevant to risk to be insured or our decision as to acceptance of
the risk or the terms upon which it should be accepted
Proposer Details

1) Full Name: Title First Name

Middle Name Surname

2) Are you an existing Bajaj Allianz Customer: Yes / No If yes, please mention the Policy No: OG
Is your name mentioned above as per your Aadhaar Card? : YES No If No, Please mention the Name as per Aadhaar Card
_____________________________________________________________________________________________________________________
3) Gender: Male Female Other 4) Date of Birth : D D M M Y Y Y Y
5) PAN No. 6) Aadhar ID :

7) Bajaj Allianz Employee Code, if Proposer is BAGIC/BALIC Employee:

8) Marital Status: Married Single 9) No. of Children Sons Daughters

10) Occupation : Business Salaried Professional Student House Wife Retired Others
11a) Permanent / Residential Address :
House No & Name

Landmark/Locality

Road/Area Name City

State Pin Code

11b) Correspondence Address : (All the communications will be sent to the below address)
House No & Name

Landmark/Locality

Road/Area Name City

State Pin Code

Telephone (Res.) Telephone (Office)

Mobile Number E-Mail _________________________________________ @ ___________________________

12) Educational Qualification: Matriculate Under Graduate Graduate Post Graduate Professionally Qualified
13) Family Monthly Income: Up to Rs. 20,000 Rs. 20,001 to Rs. 50,000 Rs. 50,001 to Rs. 1 lakh Above Rs. 1 lakh
14) In case of any Offer, you would prefer to be contacted by: Phone Email
Vehicle & Cover Details
1) Period of Insurance: From: D D M M Y Y Y Y To: D D M M Y Y Y Y 2) Licence Type: Permanent Learning
3) Renewal of the Policy will not be allowed without availability of a valid PUC Certificate* of the Vehicle (*Not Applicable till One Year from the date of first
registration of the Vehicle)
Do you have valid PUC Certificate?

4) Age at which you got the license: 5) Registration No. :

6) Date of Registration : D D M M Y Y Y Y 7) Registration Authority :

8) Year of Manufacture: Y Y Y Y 9) Date of purchase of the vehicle by You : D D M M Y Y Y Y

10) Whether the vehicle was New or Second Hand at the time of purchase
11) Engine no: Chassis No:
12) Make: Model :
Subtype :

13) Cubic capacity : Seating capacity: Driver (1) +

14) Fuel Used: Petrol Diesel LPG CNG Electric Any other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 15) Kilometer reading as on date
16) Whether any modifications/ conversions have been done on the maker's standard specification
If yes, please give details : __________________________________________________________________________________________________________
17) Is the vehicle fitted with anti-theft device: Yes No
18) Do you own another Car: Yes No If yes, please provide Vehicle Make_______________________________ and Model________________________

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19) Hypothecation Details: Name of Financial Institution/Bank:
Loan Account Number:

D D M M Y Y Y Y

Driver Details

PA Owner Driver : Nomination Details

1) Personal Accident Cover for Owner -Driver is compulsory under Private Car/Two Wheeler Package Policy. Please give the details of Nominations.
a) Name of the Nominee:
b) Age of the Nominee: c) Relationship of the Nominee to the Owner-Driver:
d) Name of the Appointee (required only if the Nominee is a minor)
e)Relationship of the Appointee to the Nominee:
Note: a) Personal Accident cover for Owner-Driver is compulsory for Sum Insured of Rs. 1 lakh for Two Wheeler and Rs. 2 lakhs for Private Cars. b) Compulsory PA cover to Owner-Driver
cannot be granted where a vehicle is owned by a company, a partnership firm or a small body corporate or where the Owner-Driver does not hold an effective driving license.
2) Do you wish to Opt for Personal Accident Cover for named Persons: Yes No
If Yes, give name & Capital Sum Insured (CSI) opted for
Sr. No. Name CSI Opted (Rs.) Nominee Relationship

(Note 1: In Case of additional persons,kindly attach a separate sheet.2)As per the provisions of IMT 15, the maximum Sum Insured available per person is Rs 1 lakh in case of Two wheeler & Rs 2 lakhs in case of Private Car.)

GST@______%

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 I/We, the undersigned hereby declare and warrant that the insurance contract and policy to be issued by Bajaj Allianz General Insurance Company Ltd [Company]
is subject to the declarations, warranties, statements and particulars given in this proposal form. I/We declare that to the best of my personal knowledge and
belief that the vehicle is in sound and roadworthy condition. I/We undertake that the vehicle to be insured shall not be driven by any person who to my/our
knowledge has been refused insurance or continuance thereof. The statements and particulars given in this Proposal form are complete, true and accurate to the
best of my/our personal knowledge and belief. I/we have clearly understood the terms and conditions [T & C] to the insurance contract and agree that the
statements and particulars given in this proposal form shall be held to be promissory and shall be the basis of the insurance contract between me/us and the
Company and the Company shall have no liability under the insurance contract if it is found that any of my/our statements or particulars or declarations in this
proposal form or other documents are incorrect and or untrue or suppressed any information or provided misleading or false information in any respect on any
matter to the grant of a cover. I/we will accept the usual T & C and form of the policy prescribed and issued by Company.
I/We hereby agree and undertake that I/we are agreeable to receive one page policy document without enclosing the T & C of policy and I hereby authorise
company that all T & C of policy can be displayed in the website of company that enables access by me/us if I/we want to know the terms and conditions of policy
displayed on website. The salient features of the policy, terms and conditions of this proposal have been explained to me/us in vernacular language, and I/we
agree to the same.
“(Please tick in case same is agreed by you)”
I / We have read and understood the Privacy Policy of your Company at www.bajajallianz.com and I hereby unconditionally agree and bind myself to all terms and
conditions of your Private Policy, as amended, from time to time.
ADDITIONAL DECLARATION TO BE GIVEN BY PROPOSER SEEKING REFUND/CLAIM AMOUNT :
I hereby agree to receive all monies due from insurance company by way of refund of premium, claims etc into my bank account as specified in the instrument
tendered towards insurance premium and such electronic transfer will constitute full and final discharge of the aforesaid obligation.

Signature of Agent/SP of Corp Agent

D D M M Y Y Y Y

No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of any kind
of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any
person taking out or renewing or continuing a policy accept any rebate, xcept such rebate as may be allowed in accordance with the published prospectus or tables of
the insurer.
Any person making default in complying with the provisions of this section shall be liable for penalty which may extend to ten lakhs rupees.
Certified that the contents of the Proposal Form and documents have been fully explained to the Proposer and that he/they have fully understood the significance
of the proposed contract ***

D D M M Y Y Y Y
DPM/APRIL-2016

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Bajaj Allianz General Insurance Co. Ltd.

DECLARATIONS – PHYSICAL PROPOSAL FORM

Are you or any of the proposal applicants a PEP* or a close relative of PEP*?

If yes, please share the details

“Politically Exposed Persons” (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign country, e.g.,
Heads of States/Governments, senior politicians, senior government/juridical /military officers, senior executives of state-owned corporations,
important political party officials, etc.” Yes / No

I/we hereby give my/our consent to the Company to verify and obtain my/our identity/address proof through CERSAI records or National
Securities Depository Limited Portal for the purpose of undertaking KYC verification. Yes / No

I/we hereby declare and confirm that the premium has been paid out of legally acquired sources of income and the subsequent premiums if
any, will continue to be paid out of legally declared and assessed source of income. Yes / No

I/We hereby give voluntary consent to BAGIC/Company to share my/our personal information and data provided in this proposal form with
its group companies or any other person in connection with the Insurance Policy or otherwise, including for providing products and services
of group companies that may be of interest to me/us, to be used in accordance with their respective privacy policies and subject to
appropriate measures being in place to safeguard my/our personal information. Yes / No