UNITED INDIA INSURANCE LTD

UNITED INDIA INSURANCE LTD CITY BRANCH OFFICE NO, 1

JOS TRUST BUILDING

CHITTOR ROAD

ERNAKULAM

.

NAME OF INSURED :

VEHICLE NO. :

POLICY NO. :

PERIOD OF INSURANCE : DECLARATION

..

I /we declare that the rate of NCB claimed by me/us is correct and that on claim has arisen in the

expiring policy period(copy of the policy enclosed ). I/we undertake that if this declaration

is found to be incorrect, all benefits under the policy in respect of section 1 of the policy will

stand forfeited.

SIGNATURE

Name and address:

Place:

Date: