12) Educational Qualification: Matriculate Under Graduate Graduate Post Graduate Professionally Qualified
16) Whether any modifications/ conversions have been done on the maker's standard specification
If yes, please give details : __________________________________________________________________________________________________________
17) Is the vehicle fitted with anti-theft device: Yes No
18) Do you own another Car: Yes No If yes, please provide Vehicle Make_______________________________ and Model________________________
Vehicle & Cover Details
10) Whether the vehicle was New or Second Hand at the time of purchase
11) Engine no:
12) Make:
Subtype :
13) Cubic capacity :
15) Kilometer reading as on date
7) Registration Authority :
5) Registration No. :
11b) Correspondence Address : (All the communications will be sent to the below address)
Telephone (Res.)
Chassis No:
Model :
Seating capacity: Driver (1) +
14) Fuel Used: Petrol Diesel LPG CNG Electric Any other
__________________________________
D
D
DM
M
MY
Y
YY
Y
YY
Y
YY
Y
YD
D
DM
M
M
6) Date of Registration :
8) Year of Manufacture:
Y Y Y Y
9) Date of purchase of the vehicle by You :
House No & Name
Landmark/Locality
Road/Area Name
Road/Area Name
City
City
State
State
Pin Code
Pin Code
D M Y Y Y YD M
Mobile Number
E-Mail _________________________________________ @ ___________________________
Telephone (Office)
House No & Name
Landmark/Locality
11a) Permanent / Residential Address :
13) Family Monthly Income: Up to Rs. 20,000 Rs. 20,001 to Rs. 50,000 Rs. 50,001 to Rs. 1 lakh Above Rs. 1 lakh
14) In case of any Offer, you would prefer to be contacted by: Phone Email
1) Period of Insurance: From: To:
2) Licence Type: Permanent Learning
4) Age at which you got the license:
3) Gender: Male Female Other 4) Date of Birth :
5) PAN No. 6) Aadhar ID :
7) Bajaj Allianz Employee Code, if Proposer is BAGIC/BALIC Employee:
8) Marital Status: Married Single 9) No. of Children Sons Daughters
Proposer Details
1) Full Name:
PRIVATE CAR / TWO WHEELER PACKAGE POLICY - PROPOSAL FORM
10) Occupation : Business Salaried
House Wife
Retired Others
Professional Student
1. Please answer all questions in BLOCK letters 2. The Liability of the Company does not commence until this Proposal has been accepted by the Company and
premium has been paid 3. This Proposal will be the basis of any subsequent policy that we issue to you. It is therefore essential that you provide all the information in
this Proposal FULLY AND ACCURATELY and that you provide us with any and all additional information relevant to risk to be insured or our decision as to acceptance of
the risk or the terms upon which it should be accepted
D D M M Y Y Y Y
Scrutiny No. Receipt No. Policy No. IMD Code Sub IMD Code IMD Name Mobile No. Emp/LG Code
2) Are you an existing Bajaj Allianz Customer: Yes / No If yes, please mention the Policy No: OG
Title
First Name
Middle Name
Surname
Is your name mentioned above as per your Aadhaar Card? : YES No If No, Please mention the Name as per Aadhaar Card
_____________________________________________________________________________________________________________________
Bajaj Allianz General Insurance Co. Ltd.,
GE Plaza, Airport Road, Yerawada, Pune - 411006. Reg No.: 113.
CIN: U66010PN2000PLC015329
Renewal of the Policy will not be allowed without availability of a valid PUC Certificate* of the Vehicle (*Not Applicable till One Year from the date of first
registration of the Vehicle)
Do you have valid PUC Certificate?
3)