PROPOSAL FORM - MOTOR INSURANCE

1. RC copy
Pls attach to email
2. Previous Insurance certificate

KINDLY WRITE ALL INFORMATION IN CAPITAL LETTERS

First Name
Last Name

Complete
Communication Address
(incl. City)
Client Details

State
Pincode
Phone number (mobile)
Emergency phone
number
Email id
Gender
Date of Birth
Marital Status
Occupation

Make of vehicle
Model & variant of
vehicle
Date of first registration
RTO
Vehicle Details

Year Of Manufacture
Vehicle registration
number
Engine number
Chassis number
Cubic Capacity (cc)
Seating Capacity
Color of the vehicle
Fuel Type

Existing insurance
company
Existing policy number

Existing policy start date

ing Policy Details

AXA - BS Confidential_CJ
 Existing Policy Details
Existing policy end date

NCB in existing policy

(%)
Did you make a claim in
existing policy?
Total amount of claims
in existing policy

Number of claims
lodged in existing policy

Name of nominee
Nominee
details

Age of nominee
Relationship with
nominee

Is the vehicle under Hire

Hypothecation

Purchase / Finance /
details

Lease Agreement /
Hypothecation?

Name of bank or
financing institution

Since how long are you

driving a vehicle
No. of people who can
Driving Details

drive in your family

Parking type at night
Annual kms driven in
your vehicle (apprx)
Age of youngest driver
in your family
Do you have a driver?

Transaction reference
Payment

number
details

Date of transaction
Amount of premium paid
(Rs.)
ents (if
Comm

any)

I / We hereby declare that the statements, answers given by me / us in this proposal form are true to the best of my
knowledge and belief. It is hereby understood and agreed that the statements, answers and particulars provided herein
above are the basis on which this insurance is being granted and that if, after the insurance is effected, it is found that
Declaration

any of the statements, answers or particulars are incorrect or untrue in any respect, the Company shall have no liability
under this insurance.

I / We agree and undertake to convey to Bharti AXA General Insurance Company Limited any change / alterations
carried out in the risk proposed for insurance after submission of this proposal form.

I/We hereby declare that all the damages observed at the time of inspection of the vehicle shall not be claimed by me/ us

AXA - BS Confidential_CJ
 Declarati
I/We hereby declare that all the damages observed at the time of inspection of the vehicle shall not be claimed by me/ us
from Bharti AXA General Insurance Co. Ltd.

FOR OFFICE USE ONLY

Inspection Agency
Vehicle Inspection

Name
applicable)
Details (if

Inspection Reference
Number
Inspection Date
Inspection time
Inspection Status

Agent Name syed mehad

Details
Interm
ediary

Agent Code 2c000014

Agent Staff code 004869

Policy Start Date (DD-

Insurance
Proposed
Period of

MM-YYYY)
Policy End Date (DD-
MM-YYYY)

WorkLine Item No.

Some Other
Information

Client ID
Receipt No.
Make and Model
User Car case
Roll Over Case

AXA - BS Confidential_CJ
NCE

LETTERS

Pls check in RC book

Pls check in RC book

1
2
3
4

5
6
7
8
9
10
11
e.g. HYUNDAI 12

e.g. SANTRO ZIP LXI 1.2 13

2003 14
Pls check in RC book 15
Pls check in RC book 16

Pls check in RC book 17

Pls check in RC book 18
Pls check in RC book 19
Pls check in RC book 20
Pls check in RC book 21
Pls check in RC book 22
23
24

Pls check existing policy 25

Pls check existing policy 26

Pls check existing policy 27

AXA - BS Confidential_CJ
 Pls check existing policy 28

Pls check existing policy 29

Yes or No 30

Pls check your claim experience 31

Pls check your claim experience

Age should be 18 years or over

Multiple choice

Multiple choice
Multiple choice

Multiple choice

Yes or No

Payment ref. no/ Cheque no.

oposal form are true to the best of my

answers and particulars provided herein
he insurance is effected, it is found that
spect, the Company shall have no liability

any Limited any change / alterations

form.

the vehicle shall not be claimed by me/ us

AXA - BS Confidential_CJ
Pls check inspection report

Pls check inspection report

Pls check inspection report
Pls check inspection report
Recommended or decline

AXA - BS Confidential_CJ
 2000

2001

1931
1932 2002
1933 2003

1934 2004
1935 2005
1936 2006
1937 2007

1938 2008
1939 2009
1940 2010
1941 2011
1942 2012
1943 2013
1944 2014
1945 2015

1946
1947
1948
1949

1950
1951
1952
1953
1954
1955
1956
1957

1958
1959

1960

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1961

1962

1963

1964

1965
1966
1967
1968

1969
1970

1971

1972
1973

1974

1975
1976

1977

1978
1979
1980

1981
1982

1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995

AXA - BS Confidential_CJ
1996
1997
1998
1999

2000

2001
2002
2003
2004
2005
2006
2007
2008
2009

2010

2011
2012
2013
2014
2015
2016
2017
2018

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2011

2012

2013 2011
2014 2012

2015 2013
2014
2015

AXA - BS Confidential_CJ
JAN MALE

FEB FEMALE
MAR YES
APR NO
MAY 0 to 1 year

JUN 1 to 2 years
JUL 2 to 3 years
AUG 3 to 5 years
SEP More than 5 years
OCT
NOV
DEC Less than 2500
2500 to 5000

5000 to 10000
10000 to 25000
Over 25000 kms

AXA - BS Confidential_CJ
MARRIED

UNMARRIED

1
2
3 or more
Covered
Open(Road Side)
Open(Inside Compound)
Recommended
Decline

AXA - BS Confidential_CJ
 Branch Co Policy TypeClient ID Inception DExpiry Dat
2C FPV 0 // //

AXA - BS Confidential_CJ
Time Agent Cod Commissio Staff. CodeReference No Receipt No Cover NoteCN Issued Inward Dat
12:00:00 AM 2c000014 #REF! 004869 0 0

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ACS ID Hypothicati Zone Seat Flag Veh. Cls Cover MAKE
NO #REF! #REF! A PV #REF! 0

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MODEL Reg No Eng No Chas No Body C.C Fuel Type Year
0 0 0 #REF! 0 P 0

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VehDOR RTA Loc IDV Elec Elec-IDV Non-Elec CNG / LPGCNG-IDV Trailer TrlReg No
// 0 #REF! #REF! #REF! #REF!

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GeoArea DrvTuition Rally/Trl SpecRally FGTank Embassy AAI Expy SideCar SideCar-ID
#REF! #REF!

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AntiTheft Handicap Vol Excess Vol Excess Vintage OwnPremisNCB (Y/N) NCB (%) Drv By Reinst TP
#REF! #REF! #REF! #REF! #VALUE! #VALUE!

AXA - BS Confidential_CJ
Restr.TPP Comp. PA Add. PA LL Drv/Em LL Oth EmpLimit/PersoLoad/Disc( iNominee NNamenee ANominee Re
#REF! #REF! #REF! #REF! #REF! #VALUE! 0 0 0

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PYP NAME Addres Addres 1 Addres 2 Policy No Expiry dateInspection
N 0 0 // TO // 0% 0 //

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Inspection NCB DeclarUsed Car Purchased Inspection Inspection ADD ON C Plan 1 ADD ON C Plan 2
N #REF! #REF! #REF! #REF!

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ADD ON C Plan 3 ADD ON C Plan 4 ADD ON C Plan 4 ADD ON C Plan 4 ADD ON C Plan 5
#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!

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ADD ON C Plan 6 ADD ON C Plan 7 ADD ON C Plan 8 ADD ON C Plan 9 Clause CodClause Cod
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Clause CodClause CodClause CodClause CodClause CodClause CodClause CodClause CodClause CodClause Cod
#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!

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Clause CodClause CodClause CodClause CodClause CodClause CodClause CodClause CodClause CodClause Codes 22
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Clause Codes 22

AXA - BS Confidential_CJ