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

JAN AROGYA BIMA POLICY PROPOSAL FORM

AGENCY CODE: ____________ DEV. OFFICER CODE: ________________

POLICY NO.: _______________ ANNUAL PREMIUM RS.________________

IMPORTANT: The Company will not be on risk until the Proposal has been accepted by the Company and the premium paid in full.

PROPOSER DETAILS

1. Name of Proposer: ______________________________________________

2. Address: _________________________________________________________

____________________________________PIN__________________

3. Details of the persons to be insured (Self/ Spouse/Son/Daughter)

Name of the Insured Person Age Sex Occupation Relationship
With the Insured Details of pre-existing diseases/ illness if any Premium
(Rs.)

4. Period of Insurance: From _________________ to ___________________(midnight)

I/We, hereby declare that the information furnished above are true and correct to my / our knowledge and belief. I/We, also declare that, I/We, am/are sound in health and am/are devoid of any disease/illness.

Place: ____________ _______________________

Date: