Personal Accident Proposal Form (Page 2 of 2) in pdf

18) Period of Insurance: From

19) Has any proposal for personal accident on your life or lives ever been postponed, declined or accepted on special terms? If yes, give

details

________________________________________________________________________________________________________________________________________

Nominee details

Name

Nominee*

Name of Nominee

DOB/Age

Relation*

% of Sum Insured

Nominee 1

Self

Nominee 2

Nominee 3

Nominee 4

Nominee

for self has to be one of the below mentioned relations.

“Father, Mother, Son, Daughter, Spouse & Others”

If Nominee is “Others” please specify --------------------------------------.(For members other than Self 100 % Nomination to the Proposer only)

Declaration

“I/We hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are true and

complete in all respects to the best of my knowledge and that I/We am/are authorized to propose on behalf of these other persons.

I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurance

company and that the policy will come into force only after full receipt of the premium chargeable.

I/We further declare that l/we will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been

submitted but before communication of the risk acceptance by the company.

I/We declare and consent to the company seeking medical information from any doctor or from a hospital who at anytime has attended on the life to be insured/proposer

or from any past or present employer concerning anything which affects the physical or mental health of the life to be assured/proposer and seeking information from any

insurance company to which an application for insurance on the life to be assured/proposer has been made for the purpose of underwriting the proposal and/or claim

settlement.

I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or claims

settlement and with any Governmental and/or Regulatory authority.”

Date

:________________________________

Signature of Proposer

Place : ________________________________

Name and Designation:______________________________________________________________________________________________________________________

Insurance Act, 1938 Section 41 - Prohibition of Rebates

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, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer .. ANY PERSON

MAKING FAULT IN COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE WITH FINE WHICH MAY EXTEND TO FIVE HUNDRED 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***

Date

:________________________________

Signature of Proposer

Place : ________________________________

Name and Designation:______________________________________________________________________________________________________________________

*** This is required only where, for any reason, the Proposal Form and other connected papers are not filled by the Prospect/Proposer.

** Please read declaration wordings carefully before signing the proposal form.