* This form consists of four pages KERALA STATE INSURANCE DEPARTMENT PROPOSAL FORM FOR INSURANCE OF MOTOR CYLES & SCOOTERS (Please answer every question fully) Proposer's (Owner's) Name ............................................................................................................. Address .............................................................................................................................................. Occupation ................................................................................................... Age .................................. Period of insurance from .............................................................................. to ................................. PARTICULARS OF VEHICLES TO BE INSURED Registered letters and numbers Make of Motor Cycle/ Scooter Cubic Capacity Year of Manufacture Date of Purchase Seating Capacity of side-car (if any) Cycle .................. without side-car Side-car Extra fittings (give details and separate values) Total Proposer's Estimate of present value Rs. 1. Name of the registering authority .. 2. Will the cycle be used solely for private purposes ? If not, sate particulars .. 3 (a) Is the proposer the sole owner of the Motor Cycle to be insured ? Is it registered in his name? (b) If the Motor Cycle is being bought under a loan or hire purchase, state the name, address of the other person or persons to be interested in the insurance .. .. 4. Is side-car attached to the Cycle? .. 5. Will the Cycle be driven SOLELY by the owner? If not, state by whom it will be driven (a) How long have the persons referred been driving a Motor Cycle? (b) Do such persons suffer from any physical infirmity, or from defective vision or hearing ? (c) Have such persons been convicted in connection with the driving of any Motor Cycle? .. .. .. .. 6. Has the proposer any Motor insurance with this or any other Company ? If so give details. .. 7. What accidents (if any) have occurred to this or to any other Motor Cycle owned or ridden by the proposer during the last three years? Give brief particulars .. 8. Is (are) Motor Cycle (s) in a perfect condition ? .. 9. Is the Motor Cycle fitted with any other accessories or fittings? If so, state separate value of these .. 10. Have you ever been insured for Motor Risks before? If so, State Policy No. and Name of the Company or Underwriter .. 11. Has any company in respect of Motor Insurance of the Proposer (a) Declined the Proposal for insurance (b) Refused to renew or cancelled the policy? (c) Increased the Premium or imposed special conditions ? (d) Required him to bear the first portion of any claim ? .. .. .. .. .. 12. Scope of cover required ? (strike off which is not applicable) (a) Do you wish that cover against Risk of Riot and Strike be excluded ? (If excluded a discount of 0.15% on I.E.V is allowed off the premium) (b) Do you wish that cover against Risk of flood etc. be excluded ? (If excluded a discount of 0.15% on I.E.V is allowed off the premium) (c) Do you wish that cover against Risk of Earthquake be excluded ? (If excluded a discount of 0.10% on I.E.V is allowed off the premium) .. .. .. Comprehensive Act liability 13. Is personal Accident Insurance to Insured or any named person and/or side-car Passenger to be included ? .. 14. Will you bear any portion of each claim ? If so, state amount. .. 15. Are you a member of a recognised Automobile Association ? If so state name of Association and Member ship number and expiry date .. .. 16. Are you entitled to No Claim Rebate or liable to Malus Loading from your Insurers ? Is so, please attach their renewal notice showing the same .. 17. State number of driver (s) and/or cleaner (s) you wish to insure against liability in addition to the liability required to be insured under the Motor Vehicles Act, 1988 .. 18. Does proposer wish to insure his legal liability to employees travelling in or driving the employer's Motor Cycle/Scooter ? .. 19. Does proposer wish insure against loss of accessories ? .. I/We HEREBY DECLARE AND WARRANT that the above statements are true and complete. I/We desire to effect to Insurance described herein within the Company, and I/We agree that this proposal and declaration shall be the basis of the Contract between me/us and the Department and I/We agree to accept a policy subject to the terms and conditions prescribed by the Department. Place ......................... ....................................... Date ................. 20......... Proposer's Signature, MOTOR CYCLE INSURANCE Permit for repairs - Urgent necessary and reasonable repairs to Motor Cycle due to accident for which the Company is liable may be authorised by insured upto a limit of Rs. 150 provided the Department is forthwith furnished with detailed estimate. Change of vehicle and change of owner -The Insurance can be transferred to cover any other vehicle purchased which replace insured vehicle. In the event of sale of vehicle the Insurance can be transferred to the purchaser. In both these cases Certificate of Insurance should be returned for obtaining a fresh Certificate and adjustment of premium will be made. The Insurance does not cover: Consequential loss, depreciation, wear and tear, breakdown, failures and damage to tyres unless the vehicle is damaged at the same time when the liability is limited to 50% The insrurance in respect for Scooter for loss or damage to vehicle is subject to a deductible excess to Rs. 50. THE FOREGOING IS ONLY A BROAD INDICATION OF THE COVER OFFERED, FOR DETAILS PLEASE REFERE TO ANY OFFICE OF THE DEPARTMENT ENSURE THAT INSURANCE IS TAKEN FOR MARKET VALUE Extra Benefits .................................. (1) Personal accident - Details of cover for the rider and Pillion rider will be furnished upon request for the cover (2) Loss of Accessories - Loss of accessories, the property of the insured by theft subject to a compulsory excess of Rs. 50 may be covered at and additional premium at 3% of the value of accessories with a minimum premium of Rs. 15. AUTHORISED DISCOUNTS (1) Insured bearing First Portion of claims for loss or damage to Motor Cycle and/or Side-car only. If the insured bears the first Rs. 100 of each and every claim -10% but not exceeding Rs. 25 If the insured bears the first Rs. 200 of each and every claim -15% but not exceeding Rs. 50 (2) If the insured as a member of any recognised Automobile Association a rebate of 5% can be allowed subject to a maximum of Rs. 15. This is not applicable to Policies issued in favour of companies or firms. (3) Bonus/ Malus clause A discount shall be allowed to the Insured or a loading shall be charged as per the table shown below on the premium for such part of the insurance as is renewed in respect of the Motor Cycle insured hereunder as per the table shown below. Loading/ Discount Position on % Loading/ Discount on own Damage own Damage premium at premium to be applied at Renewals expiry of the policy If claims is made during expiring If no claim is made during policy year expiring policy year With 40% loading Continue 40% loading Charge 30% loading With 30% loading Charge 40% loading Charge 20% loading With 20% loading Charge 30% loading No loading/discount No loading/No discount Charge 20% loading Allow 15% discount With 15% discount No loading/discount Increase discount to 25% With 25% discount Reduce discount to 15% Increase discount to 30% With 30% discount Reduce discount to 25% Continue discount to 30% INSURANCE ACT, 1938 Section 41 - Prohibition of Rebates (1) No person shall allow or offer to allow, either directly or indirectly, as an inducemant, 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 of renewing or continuing a policy accept any rebate, except, such rebate as may be allowed in accordance with the published propectuses of 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.
