UNITED INDIA INSURANCE COMPANY LIMITED

MOTOR INSURANCE PROPOSAL FORM –Commercial / Miscellaneous Type-vehicles

MOU / Development Officer’s Name & Code:

Broker’s/Agent’s Name & Code:
Proposer’s Name PAN Number :

Address for Correspondence

Telephone & Fax Number
E-mail Address
HPA/Hypothecation

Type of Policy Required Package Liability

Period of Insurance From To
Details of Vehicle
Regn.N Eng.No.& Year of Make& Cubic Seating Gross Fuel Used
o. Chassis Make Model / Capacity/ Capacity Vehicle
No. Type of HP Weight
Body

Value of the Vehicle:

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Invoice Electric/ Non- Trailer LPG/CNG Total Value IDV

Value Electronic Electrical Kit
Accessories Accessories

History of Vehicle:
Previous Type of Name of Entitlement Date of Claim Date of first
Policy No cover Insurer & of No Claim Expiry Experience Purchase &
Place Bonus for last 3 Regn.
years

Usage of the Vehicle:

Nature of Permit National/Zone/State Details of Driver Self/Paid
Private Carrier Name & Age
Public Carrier Driving License No &
Type
Stage/Contract Bus/Taxi/Auto Date of Expiry
Carriage Maxicab
Miscellaneous types No. of accidents
of vehicle involved
Has any Insurance Company declined your proposal or cancelled your Motor Policy
Discounts & Loading:
Is the vehicle fitted with the any Anti-Theft Yes/No If yes, attach certificate of installation
Device approved by ARAI issued by AASI
Whether the vehicle is driven by non- Yes/No If yes, please specify the details
conventional source
Whether the vehicle is driven by Bi-fuel kit / Yes/No If yes, please specify the details
Fibre Glass Tank Fitted
Do you wish to restrict TPPD cover to Yes/No
Statutory limit of Rs.6000/-only
Add-on Covers required
Legal Liability to Driver, Cleaner, Conductor
 Legal Liability to Other Workmen
Legal Liability to Non Fare Paying Passengers
Legal Liability to Passengers
PA cover to Driver/Cleaner/Conductor

PA to unnamed hirer/driver

Other Details
Whether use of vehicle is confined to sites Yes/No

Whether the vehicle is designed for use of Yes/No If yes, please specify the details of
blind/handicapped/mentally challenged Endorsement by RTA
persons
Whether the vehicle is used for Driving Yes/No
Tuitions
Whether extension of Geographical Area is Yes/No If yes, State the Name of the Country Nepal
required Bangaladesh,Bhutan,Maldives, Pakistan,SriLanka
Do you wish to have a one page policy? Yes/No
P * Policy terms and conditions are as per India
Motor Tariff and are displayed at www.uiic.co.in

Driver Details
Name Age DL No., Date of first issue and Type of licence Endorsements Details of
Issuing Authority held, Badge physical
number infirmities, if
any
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DECLARATION BY THE INSURED

I/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 I/We hereby agree that his declaration shall form the basis of the contract between me/us and the UNITED INDIA
INSURANCE CO. LTD.
I/We also hereby declare that any additions or alterations carried out after the submission of this Proposal Form then the
same would be conveyed to the Insurers immediately.
I/we wish to confirm that there has been no accident to my/our vehicle since the last Policy Expiry Date till now. I/We confirm
that I/We have remitted the premium at……………………………on…………………. For the insurance of the above vehicle
with you. It is understood and agreed that you have no liability or whatsoever nature for any Loss/Damage/Liability arising
out of any accident earlier to ……………..(time).
I/We declare that the vehicle is in perfect state and roadworthy condition..

PLACE:
DATE: SIGNATURE OF THE PROPOSER

VEHICLE INSPECTION REPORT

INSPECTED BY
DESIGNATION
TIME & DATE
COLOUR REGN.NO ENGINE NO CHASIS NO KM READING

I confirm that the vehicle is in externally good condition and recommended for acceptance of
coverage for IDV as declared by the Insured.

PLACE:
DATE: SIGNATURE OF THE INSPECTING PERSON