THE ORIENTAL INSURANCE COMPANY LIMITED
Regd.Office:Oriental House,P.B.No.7037,A-25/27,Asaf Ali Road,New Delhi-110 002

PROPOSAL FORM FOR “NAGRIK SURAKSHA POLICY
(PERSONAL ACCIDENT WITH HOSPITALISATION EXPENSES INSURANCE POLICY)
1. Full Name of the proposer :
2. Full Name & address of the person to be
insured & relation with the proposer :
3. Occupation/Profession of the person
to be insured :
4. Annual Income of the person
to be insured :
5. Date of Birth of the person to be insured :
6. Particulars of disablement/injury/sickness ,
if any, of the person to be insured :
7. Details of the similar other Insurance
policy(ies)held ,if any, by the person to be
insured
8. Sum Insured
( I ) Personal Accident Section : Rs.____________(80% of T.S.I)
(II) Hospitalisation Section : Rs.____________(20% of T.S.I.)
(III)Total SUM IINSURED(I+II) : Rs.________________
9. Nationality :
10. Proposed Period of Insurance : From_____________to____________
DECLARATION
I hereby declare that the above declaration is true to the best of my knowledge and belief and that I have disclosed all the particulars for the acceptance of the risk. I agree that this proposal and declaration shall be the basis of this contract between me and the Insurance Company.
Signature of the proposer/insured
Place____________________ Date:________________
ASSIGNMENT
I _______________ hereby assign the moneys payable, in the event of my death, arising out of accident payable under the policy, by The Oriental Insurance Company Limited, to Mr./Ms.____________________(relation with the insured)___________and I further declare that his/her receipt shall be final and sufficient to the Insurance Company.
Signature Name and address of the witness_________________ Signature of the Proposer/Insured ____________________
______________________________________
Place:___________________ Date:___________________
PROHIBITION OF REBATE
1. Section 41 of the Insurance Act 1938 provides as follows:
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 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 prospectus or tables of the Insurer.
2. Any person making default in complying with provision of this section shall be punishable with fine which may extend to five hundred rupees.
THE ORIENTAL INSURANCE COMPANY LIMITED
REGD.OFFICE: ORIENTAL HOUSE A-25/27 ASAF ALI ROAD NEW DELHI-2
A NOVEL ACCIDENTAL INSURANCE COVER
SALIENT FEATURES AT A GLANCE