The New India Assurance Company Limited

Head Office: 87, M G Road, Fort, Mumbai-400001 RAJRAJESWARI MAHILA KAL AN !IMA
the Com a!" a!d the remium aid i! fu$$()

"JANA #R"#"SAL $"RM

(IM#"RTANT: The Com a!" #i$$ !ot be o! ri%& u!ti$ the 'ro o%a$ ha% bee! acce ted b" 1. *ame of 'ro o%er: ++++++++++++++++++++++++++++++++++++++++++++++ 2. ,ddre%%: +++++++++++++++++++++++++++++++++++++++++++++++++++++++++
++++++++++++++++++++++++++++++++++++++++++++++++++++++++

3. ,-e (Com $eted .ear%): +++++++++++++++++++++++++++++++++++++++++++++ 4. Occu atio!: ++++++++++++++++++++++++++++++++++++++++++++++++++++++++ 5. (a) Marita$ /tatu%: +++++++++++++++++++++++++++++++++++++++++++++++++++
(b) *ame a!d a-e of the hu%ba!d: ++++++++++++++++++++++++++++++++++++++ (0f a $icab$e)

6. Co1er re2uired: +++++++++++++++++++++++++++++++++++++++++++++++++++++++

('$ea%e % ecif" #hether ba%ic or ba%ic #ith e3te!ded co1er) 7( *omi!atio! detai$%: *ame: ++++++++++++++++++++++++++++ ,ddre%%: +++++++++++++++++++++++++++ Re$atio!%hi #ith 'ro o%er: +++++++++++++ 6( *ame 5 ,ddre%% #ith /i-!ature 4it!e%% to !omi!atio! 1( *ame 5 ,ddre%% #ith /i-!ature

%& #o'icy #eriod () year to * years+, ------------- year(s+ .& #eriod o/ Insurance, $rom ---------------------------)0&78C9,R,T0O*: ---------------to

0 dec$are that 0 ha1e e3 $ai!ed the 2ue%tio!% to the 'ro o%er that the 'ro o%er:% a!%#er% thereto ha1e bee! recorded b" me a!d that he;%he ha% affi3ed hi%;her %i-!ature thumb im re%%io! after %ati%f"i!- him%e$f;her%e$f that the a!%#er% ha1e bee! correct$" recorded( 1. 8<0/T0*G 70/,=090T.: 0 hereb" dec$are that 0 do; do !ot %uffer from $o%%;di%ab$eme!t ;i!ca acit" of +++++++++++++++++++ a!d 0 u!der%ta!d that the Com a!" %ha$$ !ot a" for the %ame i! the e1e!t of a!" accide!ta$ i!>ur"( 2. 0 dec$are that the 2ue%tio!% #ere e3 $ai!ed to me fu$$" b" /hri;/mt;?umari +++++++++++++++++++++++++ a!d that the a!%#er% thereto ha1e bee! recorded b" him;her u!der m" dictatio! a!d that 0 ha1e affi3ed m" %i-!ature;thumb im re%%io! after %ati%f"i!- m"%e$f that the" ha1e bee! correct$" recorded( ++++++++++++++++++++++++++++++++ /i-!ature of er%o! #riti!- the a!%#er% 7ate: /i-!ature;thumb 0m re%%io! of 'ro o%er 7ate:

0;4e, hereb" dec$are that the i!formatio! fur!i%hed abo1e are true a!d correct to m";our &!o#$ed-e a!d be$ief( '$ace: +++++++++++ 7ate: ++++++++++++ ++++++++++++++++++++++++++++++ /i-!ature of 'ro o%er

#R"HI!ITI"N "$ RE!ATES: The fo$$o#i!- i% a! e3tract of /ectio! 41 of 0!%ura!ce ,ct 1@A8 1( *o er%o! %ha$$ a$$o# or offer to a$$o#, either direct$" or i!direct$", a% a! i!duceme!t to a!" er%o! to ta&e out or re!e# or co!ti!ue a! 0!%ura!ce i! re% ect of a!" &i!d of ri%& re$ati!- to $i1e% or ro ert" i! 0!dia, a!" rebate of the #ho$e or art of the commi%%io! a"ab$e or a!" rebate of the remium %ho#! i! the o$ic"B !or %ha$$ a!" er%o! ta&i!- out or re!e#i!- co!ti!ui!- a o$ic" acce t a!" rebate, e3ce t %uch rebate a% ma" be a$$o#ed i! accorda!ce #ith the ub$i%hed ro% ectu%e% of rebate% of the 0!%urer( 6( ,!" er%o! ma&i!- defau$t i! com $"i!- #ith the ro1i%io!% of thi% %ectio! %ha$$ be u!i%hab$e #ith fi!e #hich ma" e3te!d to fi1e hu!dred ru ee%( N"TICE, Ma3imum amou!t recei1ab$e: ,tte!tio! i% dra#! to Co!ditio! *o( C abo1e #he! the 0!%ured i% ha1i!- more tha! o!e Ra>ra>e%#ari Mahi$a ?a$"a! =ima .o>a!a i! force at the time of the accide!t or i!>ur"( Re!e#a$ of the 'o$ic" after e3 ir": 0t #i$$ be !ece%%ar" for the 0!%ured to co!tact the !eare%t office a!d obtai! a fre%h i!%ura!ce after the e3 ir" of the 'o$ic" a% re!e#a$ !otice or i!timatio! #i$$ !ot be %e!t b" the office(