The New India Assurance Company Limited
Head Office: 87, M G Road, Fort, Mumbai-400001

SUHANA SAFAR POLICY

PROPOSAL CUM SCHEDULE

Please fill and details and read the document carefully to help us serve you better.
PROPOSER'S DECLARATION
Please write in block letters

Name & address of the proposer:

Pin Code:

Date & Place of Departure: Mode of Transport Rail/Road/Air/Water:
. By
Schedule time of Departure:

Details of schedule return to the place of departure:

SECTION - 1: Personal Accident
Details of Proposer and accompanying family members (Spouse and dependant children only)

Name Age Relationship with Proposer Existing Disability if any Name & Address of Assignee
1
2
3
4
5
6
7
8

SECTION II: Baggage (Excluding articles of jewellery, and or otherwise made up fully or partially of precious of / semiprecious metals, stones, money, securities, manuscripts, deeds, bonds, Bills of Exchange, Promissory Notes, Stocks of Share Certificates, Stamps and travel tickets or traveller cheques, business books or documents)

Description of goods exceeding Rs.500/- per item

Description of goods Value (Rs.)
Description of goods Value (Rs.)

(i) (vii)
(ii) (viii)
(iii) (ix)
(iv) (x)
(v) (xi)
(vi) (xii)
Grand Total

I hereby declare that the particulars given herein are correct to my knowledge and belief and I have not withheld any information, which is material to this Insurance

Date ________ Place_________ ___________________________

SIGNATURE OF PROPOSER