COMPREHENSIVE GENERAL LIABILITY PROPOSAL FORM IMPORTANT : This proposal for insurance will be the basis of any subsequent insurance policy that we issue to you. It is essential that you answer fully and accurately all the questions contained in this proposal form, and that you provide us with any and all additional information rel evant to the risk to be insured for our decision as to the acceptance of the risk or the terms upon which it should be accepted. Your failure to comply with this obligation now may result in the rejection of your claim and the avoidance of your policy when a claim is made. If you are in any doubt about the information to be given, please seek the advice and guidance of your insurance adviser or agent. If there is insufficient space in this proposal form for you to provide relevant information, whether as requested or otherwise, please attach a separat e sheet to this proposal form and return it to us. The liability of the Company does not commence until acceptance of the proposal has been accepted and the premium has been received in accordance with the provisions of Section 64VB of the Insurance Act, 1938 ALL QUESTIONS MUST BE ANSWERED BY THE PROPOSER AND APPRORI ATELY MARKED ‘ ‘ WHERE APPLICABLE. No. Ite m SECTION A- GENERAL INFORMATION 1. Name of Firm 2. i) Address of Firm If more than one, please give each address and indicate Partner or Principal who is responsible for work at each address. ii) Applicant is …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… ……… Sole Proprietor ( ) Partnership ( ) Corporation ( ) Other ( ) 3. When was the Firm established? If new kindly provide details of experience of the key employees? …………………………………………………………………………………… …………………………………………………………………………………… …………………………………………………………………………………… ……… 4. During the past five years has the name of the firm been changed or has other business been purchased or any merger or consolidation taken place ? If “YES”, please give details YES ( ) NO ( ) …………………………………………………………………………………… …………………………………………………………………………………… Bajaj Allianz General Insurance Company Limited Bajaj Allianz House, Airport Road, Yerawada,Pune - 411006. Reg No.: 113 CIN: U66010PN2000PLC015329 UIN: IRDAN113RP0001V01200708 Page 1 of 11
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COMPREHENSIVE GENERAL LIABILITY PROPOSAL FORM
IMPORTANT :
This proposal for insurance will be the basis of any subsequent insurance policy that we issue to you. It is essential that you answer fully
and accurately all the questions contained in this proposal form, and that you provide us with any and all additional information relevant
to the risk to be insured for our decision as to the acceptance of the risk or the terms upon which it should be accepted. Your failure to
comply with this obligation now may result in the rejection of your claim and the avoidance of your policy when a claim is made. If you are
in any doubt about the information to be given, please seek the advice and guidance of your insurance adviser or agent. If there is
insufficient space in this proposal form for you to provide relevant information, whether as requested or otherwise, please attach a separate
sheet to this proposal form and return it to us.
The liability of the Company does not commence until acceptance of the proposal has been accepted and the premium has been received in
accordance with the provisions of Section 64VB of the Insurance Act, 1938
ALL QUESTIONS MUST BE ANSWERED BY THE PROPOSER AND APPRORIATELY MARKED ‘ ‘ WHERE APPLICABLE.
No.
Ite
m
SECTION A- GENERAL INFORMATION
1. Name of Firm
2.i) Address of Firm
If more than one, please give each address
and indicate Partner or Principal who is
responsible for work at each address.
ii) Applicant is
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
………
Sole Proprietor ( ) Partnership ( ) Corporation ( ) Other ( )
3.When was the Firm established?
If new kindly provide details of experience
of the key employees?
……………………………………………………………………………………
……………………………………………………………………………………
……………………………………………………………………………………
………
4. During the past five years has the name of
the firm been changed or has other business
been purchased or any merger or
consolidation taken place ?
If “YES”, please give details
YES ( ) NO ( )
……………………………………………………………………………………
……………………………………………………………………………………
Bajaj Allianz General Insurance Company LimitedBajaj Allianz House, Airport Road, Yerawada,Pune - 411006. Reg No.: 113 CIN: U66010PN2000PLC015329