THE ORIENTAL INSURANCE COMPANY LIMITED
Regd. Office: Oriental House, A-25/27, Asaf Ali Road, New Delhi-110002

PROPOSAL FORM
PRAVASI BIMA YOJANA POLICY-2006
ELIGIBILITY:
This insurance scheme is available to all Indians Citizens who apply for and obtain an
emigration clearance as required under the Emigrant Act, 1983 (31 of 1983) between the age
group of 18-60 years whilst stay abroad for the purpose of employment only, for the period of
cover as stated in the schedule to the policy.
IMPORTANT NOTICE:
This Proposal Form must be completed and signed in all respect to the best of
the proposer’s knowledge and belief and all material facts* must be disclosed.
• A material fact is one that is likely to influence the acceptance or
assessment of the Proposal.
• Non-disclosure of material facts, providing wrong or misleading
information or fraud by the insured will nullify the cover under the policy
issued.
1.0 PERSONAL DETAILS:
1.1 Name (Mr/Mrs/Miss):_________________________________________________
(BLOCK LETTERS)
1.2 Father/Spouse’s Name: __________________________________________________
1.3 Sex: Male / Female: ____________________________________________________
1.4 Date of Birth: _____ / _____ / ______ (DD/MM/YYYY) Age _____________________
1.5 Height: _________ft. _______ inch (____cms.) Weight:_______ lbs ______ (Kgs.)
1.6 Passport No.: _________________________________________________________
1.7 a) Date of Issue: ____ /____ /_____ (DD/MM/YYYY) b) Place of Issue: ____________
1.8 Address of the proposer in India: __________________________________________
_____________________________________________________________________
Pin Code: _______________Tel. No.: _______________________________________
THE ORIENTAL INSRUACNE COMPANY LIMITED 2
1.9 a) Details of Spouse and / or children (maximum two) of the Proposer:-
S.No
.
Name Sex Relation Date of Birth Age
1.
2.
3.
b) Address: _____________________________________________________________
____________________________________Tel. No.___________________________
2.0 Country of Employment: _________________________________________________
2.1 Addresses in Country of Employment __________________________________________
_____________________________________________________________________
________________________________________Tel.No.: ______________________
2.2 Name & Address of work place the proposer is attending: _______________________
_____________________________________________________________________
__________________________________________Tel. No.: ___________________
3.0 a) Brief details of employment to be undertaken: _____________________________
_____________________________________________________________________
_____________________________________________________________________
b)Period of Contract From:____________________to _________________________
(Note: please attach attested copy of the appointment letter)
3.1 Name & Address of Overseas Employer / Sponsor: ____________________________
_____________________________________________________________________
Relationship: __________________________________________________________
4.0 Period of Insurance Required: ____________________________________________
4.1 Commencement Date:__________/___________/________________ (DD/MM/YYYY)
5.0 PROPOSER’S MEDICAL HISTORY:
ANSWERS TO THE FOLLOWING QUESTIONS ARE TO BE GIVEN AS YES OR NO (A
DASH IS NOT SUFFICIENT)
5.1 Is the proposer in good health and free from physical defect or infirmity? YES /NO
5.2 Does the proposer ordinarily enjoy good health? YES /NO
5.3 Are there any additional facts affecting the proposed insurance, which should be
disclosed to insurers? ___________________________________________________
_____________________________________________________________________
THE ORIENTAL INSRUACNE COMPANY LIMITED 3
6.0 Please attach a copy of the Medical Report of the Proposer, if any, which was required
for Entry Visa. _________________________________________________________
_____________________________________________________________________
7.0 DECLARATION:
I hereby declare that I have read the prospectus and understood the policy terms & conditions
and that the particulars contained herein are true and correct and that no material fact has been
withheld/misstated or misrepresented and also this PROPOSAL FORM forming part of the
company’s standard policy shall be the basis of the contract between me and the company.
Date: ____/______ /_____ (DD/MM/YYYY)
Place: ______________ Signature of Proposer _________________
8.0 ASSIGNMENT:
I, ________________________________________ do hereby assign the moneys
payable by The Oriental Insurance Company Limited, in the event of my death to
Mr./Mrs. (Name)______________________________________ (relation to the
insured) __________________________________________ and I further declared
that in the event of death of the Assignee named herein all benefits shall become
payable to the children named in the Policy and I further declare that his/her/their
receipt shall be sufficient discharge to the Company.
Date: ____/______ /_____ (DD/MM/YYYY)
Place: ______________ Signature of Proposer _________________
Witness: 1.
2.
UNDERTAKINIG,
Mr/Mrs/Miss _____________________________________________________ do hereby solemnly
declare and state that all information given above are true and correct to the best of my
knowledge. In case any such information is found at any time in future to be false or
misleading or it is found by the insurer that I have not disclosed any fact which is material
to the assessment of the risk, the insurance cover granted to me shall be deemed to be null
and void and I shall not be entitled to any benefit thereunder .
Date: ____/______ /_____ (DD/MM/YYYY)
Place: ______________ Signature of Proposer _________________
PROHIBITION OF REBATES
Section 41 of the Insurance Act, 1938
(1) No person shall allow, or offer to allow, either directly or indirectly as an
inducement of any person to take out of 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 this
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 the provisions of this section shall
be punishable with fine which may extend upto five hundred rupees.