* This form consists of two pages GOVERNMENT OF KERALA KERALA STATE GOVERNMENT INSURANCE DEPARTMENT PACKAGE INSURANCE PROPOSAL FOR MAHILA PRADHAN AGENTS/SAS AGENTS UNDER N.S.S. FOR PERSONAL ACCIDENT MONEY IN TRANSIT AND FIDELITY GUARANTEE INSURANCE 1. Name in full : ................................................................. (in block letters) 2. Residental address : ................................................................. ................................................................. ................................................................. ................................................................. 3. Full name and address of employer : ................................................................. ................................................................. ................................................................. 4. Date of birth : ................................................................. 5. Profession/ trade or bussiness : ................................................................. (please describe fully the nature of duties) 6. Average monthly income : ................................................................. 7. Name and address of nominee with : ................................................................. relationship ................................................................. Personal accident 1. Capital sum insured : ................................................................. 2. Existing disability if any : ................................................................. 3. Have you ever claimed or received compensation under any accident policy (if so give particulars ) : Yes/No Money-in- transit 1. Daily cash collected by the employees : Rs................................ from the time of collection, during round, and until delivered at the nearest post office. 2. Capital sum insured : ................................................................. (Estimated amound in transit during the year) 3. Have you ever proposed for a similar insurance. If so to whom and with what result : FIDELITY GUARANTEE 1. Amount of security requried : ................................................................. 2. State salary and give full particulars : ................................................................. 3. Have you any private or bussiness debts or : ................................................................. liabilites. If so, state the amount. 4. Have you any source of income besides the remuneration derived from the : Yes/No employment for which the guarantee is required. (If so give particulars) 5. Have you ever applied for a gurantee to : Yes/No this or from any other insurer(If so name of company) Period of insurance I hereby declare and warrant that the above statements are true and complete. I agree that this proposal shall form the basis of contract should ther insurence be effected. If after the insurence is effected, if it is found that the statement, answers or particulars stated in the proposal form are incorrect or untrue in any respect the Insurance Department shall incur no liability under this insurance. I agree to accept the policy subject to the terms, conditions and exceptions prescribed by the insurance department . Place: Signature of proposer Date:
