Motor Insurance Proposal Form (For Individuals Only)

  Name of Proposer
  Address
  Telephone No
  Cellular No
  Fax No
  Insurance cover required from date
  Last Insured with
  Is the Proposer owner of the vechile
Yes No
  Is the vechile being acquired under Hire/Purchase
Yes No

  Cover Required Please Tick One  
 
Act Only      Third Party Liability     Comprehensive    

  Particulars of Vechile  
                   Make
                 Model
  Registration No
  Engine No
  Chassis No
  Horse Power
  Colour
  Estimated value Rs.

Declaration
 
I\We desire to ensure the above vechile with Central Insurance Company Limited, and/ we hereby declare that the particulars given above are correct in all aspects. This form will be the basis of the contract between me and the insurer / incorrect statement in the form will result in the policy being null and void from inception.
  
  Name Date
  Liability does not commence untill the proposal has been accepted by the company and the premium paid