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IPF Individual Personal Accident

This document is an application form for a personal accident insurance policy from IFFCO-TOKIO General Insurance Co. Ltd. It requests information about the applicant such as name, address, occupation, income, health history, and current insurance coverage. The form also allows the applicant to select the capital sum insured and optional extension covers. Additionally, it provides details on family package coverage where other family members can be included. The applicant must declare that all information provided is accurate to the best of their knowledge.

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Mantra Services
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134 views3 pages

IPF Individual Personal Accident

This document is an application form for a personal accident insurance policy from IFFCO-TOKIO General Insurance Co. Ltd. It requests information about the applicant such as name, address, occupation, income, health history, and current insurance coverage. The form also allows the applicant to select the capital sum insured and optional extension covers. Additionally, it provides details on family package coverage where other family members can be included. The applicant must declare that all information provided is accurate to the best of their knowledge.

Uploaded by

Mantra Services
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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IFFCO-TOKIO GENERAL INSURANCE CO. LTD.

Regd. Office: 34, Nehru Place, New Delhi-110019


Pune Branch Office: A-301, Kapil Towers, 45 Ambedkar Road, Near RTO, Pune-411001

PERSONAL ACCIDENT INSURANCE PROPOSAL FORM


FOR OFFICE USE ONLY
Agency Code Date & Time of Receipt
Rate Remarks
Policy No. Collection / Scroll No.
Accepted By

Proposer’s (Owner’s) Name:

Address:

Occupation/ Business Address


Period of Insurance From To

Profession; Occupation, Trade or Business:


(Please describe fully with nature of duties)

Are you primarily engaged in administrative function. Yes/No

Does your occupation requires you to engage in manual labour. Yes/No

Do you engage in:


a) Racing on wheels or Horseback Yes/No
b) Big game hunting Yes/No
c) Mountaineering Yes/No
d) Winter sports, skiing or ice hockey Yes/No
e) Ballooning or polo or Sports of similar nature Yes/No
What is your average monthly income from:
i) Gainful Employment Rs………
ii) Other sources Rs………
Total Rs………

Date of Birth
Height ……… Meters
Weight ……… Kgs
Have you suffered or do you suffer from:
(Full particulars must be given in case the answer is ‘Yes’ to any of the
following queries)
Any physical defect or infirmity Yes/No
Gout or Arthritis or Diabetes, Paralysis Yes/No
Fits or any kind or any other chronic disease Yes/No
Any other disability Yes/No
Have you ever proposed for Accident Life Insurance Yes/No
If so, giver name of each Company and Amount of Insurance Yes/No

Has any Company


i) Declined to issue a policy to you? Yes/No
ii) Declined to continue your Insurance. Yes/No
iii) Not invited the renewal of your Policy? Yes/No
iv) Imposed any restriction or special conditions? Yes/No
If so, give names and address of each Company in Respect of i), ii) and iv)
above.

Is this insurance to be additional to any other Accident Policy or Yes/No


Employee Scheme: If so give Particulars of all other policies
i. Name of Co.
ii. Sum insured
iii. Policy No.
Have you ever claimed/received compensation under any Accident Policy? Yes/No
If so, give full particulars, name of insurer, Amount and dates.

Please indicate Capital Sum Insured Rs…


Table of cover
i) Table A -- Benefit 1
ii) Table B1-Benefit 1 to 4
iii) Table B-Benefit 1 to 5
iv) Table C-Benefit 1 to 6
Do you wish to obtain cover against additional Risks mentioned under Yes/No
extension cover.
If yes, specify which Option (Option 1 Option 2 Option 3 Option 4)
Medical Extension Yes/No
Cost of Travel for any Relaion,friend,colleague Yes/No
Cost of Travel for Insured Person following Accident. Yes/No
Cost of supporting items Yes/No
In case any member is suffering from any disability or decease, kindly give
full details

FAMILY PACKAGE COVER


Name of Relationship Profession Annual Table & Capital Sum Extension
family with Insured or Income Insured
members & Age occupation
Table CSI Medical Cost Cost of
A, B1, of Travel Supporting
B, C Items

I declare that the above answers are true to the best of my knowledge and belief, that I have disclosed all
particulars affecting assessment of the risk. I agree that this proposal and declaration shall be the basis of the
con tract between me and this Company.

Place:
Proposer’s Signature
Date:

ASSIGNMENT:
I,…………………………..DO HEREBY ASSIGN THE MONIES PAYABLE BY THE IFFCO-TOKIO General
Insurance Co.Ltd., in the event of my death to Shri/Smt/ Kum………………………………..
…………………………………….……………………………………..
(Name & Relationship to the Insured) and I further declare that his/her/their receipt shall be sufficient
discharge to the Company.

B. Dated this…………...day of……….….2000………..……at……..………

WITNESS: 1.Name & Address:

Signature

Signature of the Policy holder

PROHIBITION OF REBATES

The following is the copy of Section 41 of the Insurance Act, 1938:


1. 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 or risk relating to lives or property in India
any rebate of the whole or part of commission payable or any rebate or the premium shown on the policy nor
shall any person taking out or renewing continuing a policy except any rebate as may be allowed in
accordance with the published prospectuses 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 to five hundred rupees.

THE PROPOSAL FORM WILL ALSO INCLUDE SALIENT FEATURES OF THE


SCHEME BEING OFFERED.

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