The New India Assurance Company Limited 
                    Head Office: 87, M G Road, Fort, Mumbai-400001 
                       
                               JANATA PERSONAL ACCIDENT POLICY
			
				      PROPOSAL FORM

1.	Name of Proposer Mr/Mrs: ______________________________________________

2.	Full Address: _________________________________________________________

                  	_________________________________________________________

3.	Age: _________________________ 4. Date of Birth: _________________________

4.	Occupation: ____________________ 6. Annual Income: Rs.____________________

7. If there is any disability Please specify: _____________________________________

8. Name of nominee: _____________________________________________________

9.His/Her Age: __________________________________________________________

10. Relation with Insured: _________________________________________________

11. His/Her full address: __________________________________________________

				___________________________________________________

12. Witness to Nomination: ________________________________________________

a)	Name: 1) ___________________________ 2) ____________________________

b)	Address: 1) _________________________ 2) ____________________________

                                 ________________________       ____________________________
  13. Capital Sum Insured: Rs. _________________________________________________
  14. Policy Period (1 year to 5 years) ___________________________________________
  15. Period of Insurance: From _______________________ to   _____________________

Date:   _________
  
Place: ___________ 					    Proposer’s Signature