MOTOR PROPOSAL FORM - :: AMC

1 THE ORIENTAL insurance COMPANY LIMITED DO 21, ORIENTAL BUILDING , 3RD FLOOR, ABOVE LIC OF INDIA, FLORA FOUNTAIN MUMBAI 400 001 TEL-022- 22853324 , 22024773 FAX NO. 022-22043700 E-MAIL- PRIVATE CAR ABRIDGED PROPOSAL form FOR ASSOCIATION OF MEDICAL CONSULTANTS (MUMBAI) AMC TEL 022-2683 6019 TELE FAX NO. 022-2682 1109 NOTE- THE ISSUE OF THE PROPOSAL form IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY, PLEASE ASK FOR THE POLICY.

2 We wish to have MOTOR Policy- PACKAGE the details of vehicle are as under. 1. Vehicle Details DATE- Regn. No. Engine No Chasis No Make/Model Year of Mfg. Cubic Capacity/GVW Prem. Rs. 2. Name, Address, Phone No. 3. Hypothecation if Any- _____ 4. Registering Authority & Place 5. Seating Capacity 6. Details of previous insurance Policy (Renewal Date _____Name & Address. Of insurance Co_____Policy No_____) enclose copy. (a) If entitled to No Claim Discount how much_____%.

3 Give copy of Renewal Notice & Policy. (b) Has any insurance company ever declined the PROPOSAL or cancelled or refused to renew or imposed special conditions. Yes/No (c) If Yes give details. 7. Period of Insurance_____To_____. DECLARATION: I/ We hereby declare that the statement made by me/us in this PROPOSAL form is true to the best of my knowledge and belief and I/We hereby agree that this declaration shall form the basis of the contract between me/us and the THE ORIENTAL insurance CO. LTD. I/We also declare that if any conditions or alterations are carried out after the submission of this PROPOSAL form the same shall be conveyed to the insurer immediately.

4 Place: Mumbai Date: Name & Signature of proposer. OUR BROKER: - Safeway insurance Brokers Pvt. Ltd. THIS DOCUMENT IS NOT, POLICY OR CERTIFICATE OF insurance OR ANY LEGAL DOCUMENT OF insurance .