Proposal Form For Janata Personal Accident Policy
The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001
JANATA PERSONAL ACCIDENT POLICY
PROPOSAL FORM
1. Name of Proposer Mr/Mrs: ______________________________________________
2. Full Address: _________________________________________________________
_________________________________________________________
3. Age: _________________________ 4. Date of Birth: _________________________
4. Occupation: ____________________ 6. Annual Income: Rs.____________________
7. If there is any disability Please specify: _____________________________________
8. Name of nominee: _____________________________________________________
9.His/Her Age: __________________________________________________________
10. Relation with Insured: _________________________________________________
11. His/Her full address: __________________________________________________
___________________________________________________
12. Witness to Nomination: ________________________________________________
a) Name: 1) ___________________________ 2) ____________________________
b) Address: 1) _________________________ 2) ____________________________
________________________ ____________________________
13. Capital Sum Insured: Rs. _________________________________________________
14. Policy Period (1 year to 5 years) ___________________________________________
15. Period of Insurance: From _______________________ to _____________________
Date: _________
Place: ___________ Proposer’s Signature
