A(I).

Personal Details of Proposer/Owner:

1 Proposer's (Owner's) Full Name (In capital letters) Mr. BINITA THAKUR

2 Address (where the vehicle is normally kept) WAAD3, ,

(In capital letters, with pin code) Gorakhpur
Personal Details

Uttar Pradesh
273007
Telephone: Fax:
Mobile No: 7986510984 Email Id: RAKESHKUMAR@GMIL.COM
3 Occupation / Business

4 Type of Cover Liability Only Policy

5 Period of Insurance From: 00:00:00Hrs on 02/07/2025
To : 00:00:00Hrs on 01/07/2026

A(II). Vehicle Details:

6 Registration Number of the Vehicle UK-04-PA-1330

7 Date of Registration of the Vehicle 06/08/2021
8 Registering Authority & Location NAINITAL
9 Year of Manufacture 2021
10 Engine Number HEOPE2104AA1872
11 Chasis Number MEPHEHPSB079L3967
12 Make of the Vehicle HERO ELECT
13 Model NYX ER
14 Type of Body SCOOTER
Vehicle Specifications

15 Cubic Capacity of the Vehicle 3

16 Seating Capacity including driver 2
17 Whether the vehicle is driven by non- conventional source of power / CNG/ LPG / Bi- YES. CNG
Fuel?
If YES', please give details
18 Whether the use of vehicle is limited to own premises?
NO
19 Whether the Private Vehicle is used for commercial purpose?
NA

20 Whether the vehicle is used for driving tuitions? (GR-44)

NO

21 Details of Hire Purchase / Hypothecation / Lease (IMT-5) (IMT-6) (IMT-7)

a) is the vehicle proposed for insurance is:

(i) Under Hire Purchase? NO
(ii) Under Lease Agreement? NO
(iii) Under Hypothecation? NO

b) If ‘YES”, give name and address of concerned party/parties:

A(III). LIABILITY SECTION: COVERAGE

22 Coverage for liability against Third Party Risks (Death or Bodily Injury) required in respect of:
Third Party Risks: Death/Bodily Injury

(i) Owner Driver only NO

(ii) Any person other than Paid Driver NO
If ‘YES”, give details of such other persons:
1)
2)
3)

(Note: 1. Section146 of Motor Vehicles Act-1988 makes it mandatory for the owner of the vehicle to ensure that he or any other person authorized by him
to drive a vehicle in public place has insurance against third party risks. The explanation to Section146 exempts the paid driver.)
2. As per Section 147 (2)(a) The liability is ‘as incurred’ in the case of death / bodily injury of a third party]

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 Risks:
23 Do you wish to have the statutory Third Party Property Damage (TPPD) liability of Rs.6000/- only?

TPPD
(IMT-
Third
Party

20)
NO

coverd by M.V Act-1988) [For additional TPPD limits, please see Q.Nc.25]

24 Legal liability to persons employed in connection with operation of the vehicle who are ‘workmen’. [The liability of the Employer under the Workmens’
Liability to 'Workmen'

(Compulsoriliy to be
under W.C.act-1923

Compensation Act-1923 is covered under the Motor Vehicles Act-1988.

Third Party Risks:

1)Drivers (No.of persons: )

2) Employees (Workmen) (No.of persons: )
(Note: The Motor Vehicles Act-1988 under Sec.147(1)(ii)(i) covers liability to employees who are workmen within the meaning of the Workmen’s
Compensation Act-1923.)
[For additional coverage, please refer to Q.No.26]

B. Questions that provide additional covers as per IMT Endorsements

Addl.TPPD

25 The Policy provides additional Third Party Property Damage liability limits of Rs.1,00,000/- for two wheelers and 7,50,000/- for other classes of
vehilces. Do you wish to cover the additional limit? NA
(GR-39)

[Refer to Q.No.23]

26
Additional

Workmen

Do you wish to cover wider legal liability to employees who are ‘workmen’? [This information is sought to cover in addition to liability under the
Liability

Workmens Compensation Act-1923, also liability under the Fatal Accidents Act-1855 and the Common Law]
(IMT-28)
to

NA

(Note: The additional liability under Common Law and Fatal Accidents Act in respect of employees who are workmen is covered under this
endorsement).
[Refer to Q.No.24]

Do you wish to cover wider legal liability to employees who are NOT ‘workmen’? NA
Employees

27
Liability to

Workmen
Who are

(IMT-29)
not

(Note: The liability under Common Law and Fatal Accidents Act-185S in respect of employees who are NOT Employee can be covered under this
endorsement).

28 Personal Accident Cover for Owner Driver is compulsory in the Liability Only Cover. Please give details of nomination:

(a) Name of the Nominee :

Cover For
Personal
Accident

Age :
Driver
Owner

(b) Relationship :
(c) Name of the Appointee :
(If Nominee is a Minor)
(d) Relationship to the Nominee :

(Note: 1. Personal Accident cover for Owner Driver is compulsory for Sum Insured of Rs.1,00,000/- for Two Wheeler and 2,00,000/- for other
vehicles.
2. Compulsory PA cover to owner driver cannot be granted where a vehicle is owned by a company, a partnership firm or a similar body
corporate or where the owner-driver does not hold an effective driving license)

29 Do you wish to include Personal Accident cover for named persons? NA

If YES, give name and Capital Sum Insured (CSI) opted for:

Name CSI Opted (Rs) Nominee Relationship

PA Cover for

(IMT-15)
Occupants
Named

1)
2)
3)
(Note: The maximum CSI available per person is Rs.2 Lakh in case of Private Cars and Rs.1 Lakh in the case of Motorized Two Wheelers)

30 Do you wish to include Personal Accident cover for Un-named Passengers/hirer/pillion passengers (Two Wheelers)?
Occupants
PA Cover

NO
for Un-
Named

(IMT-16)

If YES, give number of persons and Capital Sum Insured (CSI) Opted:
No. of Persons: C.S.I (Per Person):

(Note: The maximum CSI available per person is Rs.2 Lakh in case of Private Cars and Rs.1 Lakh in the case of Motorized Two Wheelers)

31 Whether extension of geographical area to the following countries required?

Geographical
Extension

(1) Bangladesh No (2) Bhutan No

(IMT- 1)l

(3) Maldives No (4) Nepal No

(5) Pakistan No (6) Sri Lanka No

(Note: Presently the territory covered is geographical area of India. Extension of geographical area cover can be availed by use of this endorsement

C. Questions that are elicited for information and data collection purposes

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 32 Previous History:
a. Date of purchase of the vehicle by the Proposer: _______/_______
Previous History b. Whether the vehicle was new or second hand at the time of purchase? : NA
c. Will the vehicle be used exclusively for
(i) Private, Social, Domestic, Pleasure or Professional Purpose? NA
(ii) Carriage of goods other than samples or personal luggage? NA
d. Is the vehicle is in good condition? NA
If NO, please give details:

e. Name and Address of the previous insurance company: Cholamandalam MS General Insur
f. Previous policy number: 3372/65105245421/000/00
g. Period of Insurance :
h. Claims lodged during the preceding 3 years:

YEAR NO. OF CLAIMS CLAIM AMOUNT (Rs.)

______________ ________________ __________________

______________ ________________ __________________

______________ ________________ __________________

33 Details of the Driver:

a. Age & Date of Birth of the Owner: Age: NA

DOB: NA
b. Age & Date of Birth of the Driver: Age: ______ Yrs DOB:____/_______/__________
Driver Details

c. Does the driver suffer from defective

vision or hearing or any physical infirmity? NA
If YES, please give details of such infirmity:

d. Has the driver ever been involved / convicted

for causing any accident of loss? NA
If YES, give details as under including the pending prosecutions:
- Driver’s Name :
- Date of Accident:
- Loss / Cost (Rs.):
- Circumstances of Accident/ Loss:

Declaration by the Insured

I/We hereby declare that the statements made by me/us in this Proposal Form are true to the best of my/our knowledge and belief and I/We hereby agree that this declaration
shall form the basis of the contract between me/us and the ____________________Insurance Company Ltd.
I/We also declare that any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the Insurance Company
immediately.

Date: 01/07/2025 Proposer's Signature: __________________________

Premium Paid by Cash/Cheque No: Date:
Bank: Amount: 0.0000

________________________________________
GSTIN : (If more than one GSTIN, Kindly Attach an annexure with details)
Please fill up the request for authorization form attached with this proposal form to receive Claim/ Refund payments if any, directly into your bank account through
NEFT if the Premium is more than Rs 25000/-

The company reserves the right to reject the said proposal or to terminate the insurance contract unilaterally and/or freeze the funds if the Customer, or persons associated with
him/her, found to be named in any recognized black list.

FOR OFFICE USE ONLY

Intermediary's Name: KAPIL KUMAR Intermediary's Code: 60116081
Sales Manager's Name: Sales Manager's Code:

PROHIBITION OF REBATES (Insurance Act-1938. Section 41)

1. 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 whole or par t 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 prospectuses or tables of the Insurer.
2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to Ten Lakh Rupees.

Future Generali India Insurance Company Limited, Corporate & Registered Office : 6th Floor, Tower - 3, Indiabulls Finance Center, Senapati Bapat Marg,
Elphinstone Road, Mumbai - 400013, Maharashtra Care Line:- 1800-220-233, 1860-500-3333, 022-67837800 Email : fgcare@futuregenerali.in, Website :
www.futuregenerali.in IRDA Regn. No 132, CIN - U66030MH2006PLCI65287

UIN : 1/RD/FGIICL/MOTORS/FS/07-08

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