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PROPOSAL FORM HOME SECURE - STANDARD FIRE AND SPECIAL PERILS POLICY (RESIDENTIAL PREMISES ONLY)

All mandatory fields marked in bold asterisk*

Note: 1. Acceptance of this proposal is subject to the rules & regulations of All India Fire Tariff. 2. The property proposed for insurance is not covered until the

proposal is accepted and premium paid. 3. Applicable only for residential buildings with RCC/RBC/TILES/ACC roof and external walls of Burnt bricks / Stone /Concrete blocks. 4. Failure to disclose facts material to the assessment of the risk or providing misleading information may render the contract void.

5. Terrorism cover can be availed provided policy period is 1 year only.

Application No.: HFN

DETAILS OF PROPERTY TO BE COVERED :

4. Address of the property to be covered (Please provide only if this is different from the address for communication)*:

City: District: State: Pin Code*:

5. Name & Address of the Financier / Mortgagee:

6. Would you like to delete following covers from the basic cover?

a. Flood, Cyclone group of perils  

Yes  

No b. Riot, Strike & Malicious Damage  

Yes  

No

7. Would you like to cover terrorism (only if Riot, Strike etc. cover is opted)*  

Yes  

No

8. Would you like to cover Earthquake (Fire & Shock) :  

Yes  

No

9. Would you like to opt for any other Add-on Covers (give details) :

10. Would you like to cover Plinth & Foundation along with your building :  Yes  No

11. Age of Building*:   < 5 Years   5-10 Years   10-20 Years   20-30 years   30-40 years   > 40 Years

12. Basis proposed for insurance : a. Market Values Basis b. Reinstatement Value Basis

13. Whether you have insured the same property with any other Insurance Company with the same type of coverage (give details) :

14. Whether Insurance was declined by any other Company or imposed any special conditions (give details):

15. Sum Insured required*: (For Bldg. please indicate the present day cost of Construction if opted on reinstatement value basis. Land value is not covered)

Sr.No. Items Sum Insured Premium Sr.No. Items Sum Insured Premium1. Building 4. Plinth & Foundation

2. Contents 5. Others

3. Add-on Cover 6. Total

PROPOSER’S DETAILS

1. Name of the Proposer*:

2 Date of Birth*: Sex : Male Female

Marital Status : Married Single

Occupation :

3. Address for communication*:

City: District:

State: Pin Code*:

Tel : (O): (R):

Mobile: E-mail:

FOR PRODUCER’S USE ONLY

Branch :

Producer Code :

Premium : Rs.

Cash / Cheque :

Dated :

Bank :

Producer’s Signature :

D D M M Y Y Y Y

D D M M Y Y Y Y

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INSURANCE ACT 1938 SECTION 41 - PROHIBITION OF REBATES

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 ofany 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 thepolicy, 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 theprospectus or tables of the Insurer.

ANY PERSON MAKING DEFAULT IN COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE WITH A FINE WHICH MAY EXTEND TOFIVE HUNDRED RUPEES.

Insurance is the subject matter of the solicitation. For more details on risks factors, terms and conditions,please read sales brochure carefully, before concluding a sale.

Tata AIG General Insurance Company Ltd.

Registered Office : Peninsula Business Park, Tower A, 15th Floor, G. K. Marg, Lower Parel, Mumbai - 400 013.

Toll Free No. 1800 266 7780 visit us at www.tataaiginsurance.in

AML Guidelines

1. I/We hereby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been/will be paid out of proceeds of crimerelated to any of the offence listed in Prevention of Money Laundering Act, 2002.

2. I understand that the Company has the right to call for documents to establish sources of funds.

3. The insurance company has right to cancel the insurance contract in case I am/have been found guilty by any competent court of law under any of thestatutes, directly or indirectly governing the prevention of money laundering in India.

● Nationality : Indian Non-Indian If Non-Indian, please specify Country :

● Type of Organization Corporations Governments Non Governmental Organizations Society Trust Partnership

International Organization Cooperatives Section 25 Company

DECLARATION

I/We desire to insure with Tata AIG General Insurance Company Limited in respect of the home described in this proposal form and confirm that thestatements contained in this application are my/our true and accurate representations. I/We undertake that if any of the statements are found to be false orincorrect, the benefits under this policy would stand forfeited. I/We agree that this application and declaration shall be promissory and shall be the basis ofthe contract between me/us and Tata AIG General Insurance Company Limited. I/We confirm that I/We have read and understood the coverages, the termsand conditions and agree to accept the Company’s policy of insurance along with the said conditions prescribed by the Company. I/We also declare andundertake that if any additions or alterations are carried out by me/us in this proposal form or if there is any change in the information as submitted by me/usafter the submission of this proposal form then the same would be conveyed to Tata AIG General Insurance Company Limited immediately failing which it isagreed and understood by me/us that the benefits under the policy would stand forfeited. I /We agree to the Company taking appropriate measures tocapture the voice log for all such telephonic transactions carried out by me/us as required by the procedures/regulations internal or external to the Companyand shall not hold the Company responsible or liable for relying/using such recorded telephonic conversation. I/We agree that the insurance would beeffective only on acceptance of this application by the Company and the payment of the requisite premium by me/us in advance. In the event of non-realization of the cheque or non-receipt of the amount of premium by the Company the policy shall be deemed cancelled ‘ab-initio’ and the Company shall notbe responsible for any liabilities of whatsoever nature under this Policy

Place: Signature of the proposer

Date: D D M M Y Y Y Y

16. Period of Insurance*: From — — / — — Hrs. On To Mid Night of

17. Any other additional information you would like to furnish/disclose:

D D M M Y Y Y YD D M M Y Y Y Y

D D M M Y Y Y Y

in the absence of PAN Card, please give details of any other authorized

photo identification card.

Premium paid by cash / Cheque No. Date Amount (Rs.)

Bank Branch

PAN card Number:

Card Type Number:

Sources of funds (please✔where applicable): Salary Business Other (Please specify)