Head Office & Regd. Office : Bajaj Allianz House, Airport Road, Yerawada, Pune - 411006.
CIN: U66010PN2000PLC015329
UIN: IRDAN113RP0002V01200708
FOR OFFICE USE ONLY
ACCEPTED BY
DATE & TIME
RATE
REMARKS
POLICY NO.
COLLECTION NO./SCROLL NO
PROPOS AL FORM FOR All Risk Policy
_
SCOPE OF COVER
This Insurance Policy provides cover against Loss or Damage to portable equipments due to perils mentioned on the
policy schedule..
EXCLUSSONS
The Insurance Policy does not cover.
a. Loss of damage arising from W ar, Warlike operations Civil Commotion, Depreciation wear and tear, moth, mildew,
vermin, the process of cleaning, dyeing repairing over winding of clocks and watches mechanical derangement,
electrical breakdown, breakage of glass, china and articles of brittle nature, theft from unattended vehicles,
detention or confiscation by Customs or other Authorities and consequential loss.
b. Money Securities, Manuscripts, Deeds Bonds, Bills of Exchange Promissory Notes Stock or Shares Certificate,
Stamps, Business Books and documents articles dispatched under contract of affreightment.
THE FOREGOING IS ONLY A BROAD INDICATION OF THE COVER OFFERED EOR DETAILS PLEASE REFER
TO ANY OFFICE OF THE COMPANY.
This type of insurance is also available under section III of Householders Policy
NOTE: PLEASE ANSWER EVERY QUESTION FULLY
1.a Name of person (in full)
(in BLOCK LETTER)
b. Residential Address
c. Occupation/Profession and address
2. PROPRETY TO BE INSURED
Sr. No. Full Description of Property Sum Insured Rs
(Ensure that the property is correctly described and insured for full value to get adequate indemnity.)
3. Has the item been recently purchased?
and if so, furnish the Invoice copy.
4. W hether cover is also required outside India.
if yes give details
5. Is the risk currently insured against Fire.
a. The name of the Company
b. Policy No.
c. Period
UIN: IRDAN113RP0002V01200708
a. Have you suffered any loss of or damage to these items in the past?
(Irrespective of whether insured or not)
b. If so, give full details thereof as under:
Amount of loss
Date of Occurrence Details of loss Name of the Insurance
Rs.
7. Has any company in respect of Insurance
a. Declined your Proposal?
b. Cancelled or refused to renew your policy?
c. Accepted your proposal on special terms and conditions?
8. Periods or Insurance
From To.
I / W e do hereby declare that the above statement and answers are true and that I / W e have not withheld any
information whatsoever regarding the proposal. I / W e agree that this proposal and declaration shall be the basis of
the contract between me/us and Bajaj Allianz General Insurance Company Ltd. W hose policy for the insurance
proposed is acceptable to me/us. I/W e undertake to excise all ordinary and reasonable precaution for safety of the
property as if it were uninsured.
I/We hereby unconditionally allow the Company to share all my / our information being collected in this proposal form or through
telephone / email / web-inputs means or other means, as updated from time to time within group entities.
Place:
Date: Proposer's Signature
PROHIBITION OF REBATES
Section 41, of insurance Act, 1938
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 the
whole or part of the con-mission payable or any rebate, of the premium shown on the policy nor shall any person
taking out or renewing or continuing a policy accept rebate except such rebate as may be allowed in accordance with
the published prospectus or tables of the insurer Any person making default in complying with the provisions of this section
shall be liable for penalty which may extend to ten lakhs rupees.
UIN: IRDAN113RP0002V01200708
Bajaj Allianz General Insurance Co. Ltd.
DECLARATIONS – PHYSICAL PROPOSAL FORM
Are you or any of the proposal applicants a PEP* or a close relative of PEP*?
If yes, please share the details
“Politically Exposed Persons” (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign country, e.g.,
Heads of States/Governments, senior politicians, senior government/juridical /military officers, senior executives of state-owned corporations,
important political party officials, etc.” Yes / No
I/we hereby give my/our consent to the Company to verify and obtain my/our identity/address proof through CERSAI records or National
Securities Depository Limited Portal for the purpose of undertaking KYC verification. Yes / No
I/we hereby declare and confirm that the premium has been paid out of legally acquired sources of income and the subsequent premiums if
any, will continue to be paid out of legally declared and assessed source of income. Yes / No
I/We hereby give voluntary consent to BAGIC/Company to share my/our personal information and data provided in this proposal form with
its group companies or any other person in connection with the Insurance Policy or otherwise, including for providing products and services
of group companies that may be of interest to me/us, to be used in accordance with their respective privacy policies and subject to
appropriate measures being in place to safeguard my/our personal information. Yes / No