Proposal form motor insurance

motor insurance proposal form

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Telephone no

occupation/profession

Is the vehicle proposed for insurance under hire purchase/hypothecation/lease agreement

If hypothecated name of financier

Type of cover required. liability only/package etc

liability

pacakage

only Package for 2nd year

only package for 3rd year

period of insurance start date and end date.

period of insurance start date

period of insurance end date

Registration No and date and registration of vehicle

Registration authority and location

Year of manufacture

engine no

chasis no

Make of vehicle

Type of body /model

Cubic capacity

seating capacity including driver

Gross vehicle weight

Maximum licenced carrying capity (No of persons)

Previous insurance details

previous policy no period of insurance and type of cover

claim lodged during last three years

Yes

claim lodged during last three years

Aadhar no

Nominee name dob/age and relation with vehicle owner

Has any company decline proposal if so give details

Valid pollution certificate

I declare that information given be me is correct .

Date / Time

Place

Proposal form motor insurance

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