Head Office & Regd. Office: GE Plaza, Airport Road, Yerawada, Pune 411 006
Bajaj Allianz General Insurance Company Limited
PRIVATE CAR INSURANCE – PROPOSAL FORM
Please answer all the questions in BLOCK letters.
If you require additional space please use space for additional information on reverse.
Failure to disclose material facts which an insurer would regard as likely to influence the acceptance and assessment of
your proposal can lead to your policy being rendered void. If in doubt as to whether certain facts are relevant, please include the
1. Name in Full
2. Date of Birth
Male / Female
4. Telephone No.:
6. E-mail address
7. Occupation and Designation
Public Sector official
Pvt Sector Official
Self Employed (give details)
Others (give details)
8. Office / Business address
9. Have you been previously insured in respect this vehicle?
10. If Yes, are you entitled for No Claim Discount from
your previous insurer? If Yes NCB percentage
and No. of years without any claim.
11. Please give name of your previous insurer
12. Previous insurance policy no. and policy period
13. Are you member of Automobile Association of India?
If yes, give details of membership
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ABOUT THE DRIVERS
The vehicle to be driven by:
You the Insured only
2. You and Your Spouse
3. You, Your Spouse and any other person named below
Please give details of main drivers / Named drivers referred above:
Note: Please mention whether the person suffer from Diabetes, epilepsy, heart condition or any other disease or infirmity (including
uncorrected defective vision or a hearing or mental defect) that could affect his/her ability to drive
Have You or any of the above drivers:
Been prosecuted or convicted for any offence or any prosecution pending?
Yes / No
Had motor insurance refused, had a policy cancelled or had any special conditions
imposed by any