Issuing Office:

COMMERCIAL VEHICLE MOTOR PROPOSAL FORM

PLEASE WRITE IN BLOCK LETTERS

Tick the box as per your requirement.
Category Commercial Vehicle

Type Tick box Name UIN

Motor Package |__| Commercial Vehicle - Package policy IRDAN106P0005V01200607

Third Party |__| Commercial Vehicle -Stand Alone TP policy IRDAN106P0006V01200607

A. Do you want Comprehensive cover with coverage for depreciation? Yes ☐ No ☐

(Applicable for Commercial Vehicle - Package policy) If Yes, further details to be provided in Add-on section.

(Add-on name and UIN is mentioned in annexure)

Personal Details
1 Registered Owner’s Full Name
GSTIN (If customer is registered for GST)
Mobile No Telephone No
Contact Details
Email ID
Address (Where the Vehicle is Flat / Building
normally kept)
Street / Road /
2 Sector
Area / Village /
Taluka
Landmark
City Pin Code
State
Communication Address Flat / Building
Street / Road /
Sector
Area / Village /
Taluka
Landmark
City Pin Code
State
Permanent Address (if different from Flat / Building
the Communication address) Street / Road /
Sector
Area / Village /
Taluka
Landmark

Motor Proposal Form – Commercial Vehicle Page 1 of 11

IFFCO TOKIO General Insurance Company Limited. CIN: U74899DL2000PLC107621, IRDA Reg No.106
 City Pin Code
State
3 Name of the Nominee
Relationship
Name of the Appointee
(If Nominee is a Minor)
Relationship to the Nominee % of Share
% of Share
4 Occupation / Business
5 KYC Details (Please attach self- KYC Document of Person ☐ AADHAR Card ☐ Voter ID card
attested photo copies) proposed to be Insured ☐ Passport ☐ Driving License
☐ NREGA Job card ☐ National Population Register Card
☐ PAN Card (mandatory where premium exceeds ₹ 10,000/-)
KYC Document Number/ CKYC
Number
To know Your CKYC No. Please give missed call on 7799022129
6 *Are You a Politically Exposed Person or related PEP? Yes ☐ No ☐
*“Politically Exposed Persons” (PEPs) are individuals who have been entrusted with prominent public functions by a foreign country, including
the heads of States or Governments, senior politicians, senior government or judicial or military officers, senior executives of state-owned
corporations and important political party officials”
7 Period of Insurance Hrs. Day Month Year
Form
To
Electronic Insurance Account Details Section:
I want my policy related documents viz. Policy Schedule, Wordings etc. in:
Physical Format- Yes ☐ No ☐
e-Format (electronic) as & when applicable- Yes ☐ No ☐
I have e Insurance Account & the No. is _____________________________
☐ I have e Insurance Account & the No is _______________________
☐ I am not having an e –insurance account & I authorize IFFCO-Tokio to open an e-insurance account.
Vehicle Specifications
8 Proposal For New ☐ Renewal ☐ Rollover ☐ Endorsement ☐
Goods Carrying Vehicle ☐
9 Type of Vehicle Passenger Carrying Vehicle ☐
Mis. D ☐ Please specify usage_________________________
10 Registration No. of the Vehicle
11 Date of Registration of the Vehicle
12 Registering Authority & Location
13 Year of Manufacture
14 Engine No
15 Chassis No
16 Make of the Vehicle
17 Model
18 Type of Body
19 Gross Vehicle Weight GCW & Cubic Capacity of the Vehicle CC/ KG.
20 Max. Licensed carrying capacity (No. of Passengers) in case
of Passenger Carrying Vehicles?
21 a) Fuel Type Petrol ☐ Diesel ☐
b) Weather Vehicle is driven by non-conventional source of Yes ☐ No ☐ If Yes ,please give details :______________
power / Electric / Hybrid /CNG/LPG/Bi-Fuel? _________________________________________________________

Motor Proposal Form- Commercial Vehicle Page 2 of 11

IFFCO TOKIO General Insurance Company Limited. CIN: U74899DL2000PLC107621, IRDA Reg No.106
 22 Whether the use of vehicle is limited to own premises? Yes ☐ No ☐
23 Type of road where vehicle would normally ply Hilly ☐ Road ☐ National /State Highways ☐ City-Town Road ☐
District Road ☐ Others ☐ __________________________________
24 Nature of goods normally carried Hazardous ☐ Non- Hazardous ☐
If Hazardous ,give details of hazardous substance ______________
________________________________________________________
25 Type of Permit (Goods Carrying Vehicle ) National ☐ State ☐ Local ☐ Zonal ☐ Hilly Areas ☐
If National permit , specify state where vehicle would be playing
___________________________________________________________
26 Is driver certified for carrying hazardous material Applicable -Certified ☐ Applicable–Not Certified ☐ Not applicable ☐
27 Whether the vehicle is used for driving tuitions? (GR-44) Yes ☐ No ☐
28 Details of Hire Purchase / Hypothecation / Lease (IMT-5) / (IMT-7) / MT-6)
a) Is the vehicle proposed for Insurance is :
i) Under Hire Purchase? Yes ☐ No ☐
ii) Under Lease Agreement? Yes ☐ No ☐
iii) Under Hypothecation? Yes ☐ No ☐
b) If “Yes “ , give Name and Address of concerned party/
Parties:
c) PUC Details: _________________; Fitness Certificate Details: _________________; Transport permit details__________________
Note: - Copies of R.C , Pollution under Control (PUC) ,Fitness Certificate (If applicable) & Transport permit (If applicable) should be
submitted along with the Proposal form.
Third Party Risk : Death / Bodily Injury
29 Coverage for Liability against Third Party Risk (Death or Bodily Injury) required in respect of:
i) Any Person other than Paid Driver Yes ☐ No ☐
If ‘Yes ‘ give details of such other persons
1)
2)
3)
Note:
Section 146 of Motor Vehicle Act-1988 makes it mandatory for the owner of the vehicle to ensure that he / she or any other
person authorized by him / her to drive a vehicle in public has insurance against third party risk. ( The explanation to Section
146 exempts the paid driver).

Third Party Risk: Liability to ‘Workmen ’ under E.C. Act.1923 (IMT -28)
30 Wider Legal Liability to persons employed in connection with operation of the vehicle, who are ‘workmen’ i.e. The liability of the
Employer under the Employees Compensation Act-1923 .
1) Paid Driver No .of Persons:________ S.No. Name
1. _________________________
2. _________________________
3. _________________________
2) Cleaner No .of Persons:________ S.No. Name
1. _________________________
2. _________________________
3. _________________________
3 Conductor No .of Persons:________ S.No. Name
1. _________________________
2. _________________________
3. _________________________
Personal Accident Cover of Registered Owner Driver
31 Personal Accident Cover for Registered Owner cum Driver is compulsory in the Liability Only Cover.
Please give details of nomination:-
a) Name of the Nominee
b) Relationship

Motor Proposal Form- Commercial Vehicle Page 3 of 11

IFFCO TOKIO General Insurance Company Limited. CIN: U74899DL2000PLC107621, IRDA Reg No.106
 c) Name of the Appointee
(If Nominee is a Minor)
d) Relationship to the Nominee
e) Period of cover From _______________________To____________________
Note:- 1) Personal Accident cover for Registered Owner cum Driver (registered owner as per RC) is compulsory for Sum Insured of ₹
15 Lakhs.
2) Compulsory PA Cover to Owner cum Driver cannot be granted where a vehicle is owned by a partnership firm or a similar
body corporate or where the owner –driver does not hold an effective driving license.
3) Kindly provide below details in case you have an existing Personal Accident policy covering Death & Permanent disability
(Total & Partial):
Policy No :_____________________________ Sum Insured : ________________________
Policy Period : From: _______________ To ______________________
Personal Accident for Named Occupants (IMT-15)
32 Do you wish to include Personal Accident cover for
Named Persons?
Yes ☐ No ☐
If Yes , give Name and Capital Sum Insured (CSI) opted
for:-
S.No Name CSI (Opted ) ₹ Nominee Name Relationship
1
2
3
4
5
Note:-The Maximum CSI available per person is ₹ 1 Lakhs in case of Motorized Two Wheelers & ₹ 2 Lakhs in case of other classes
of vehicles.
PA Cover for Un-Named Occupants (IMT-16)
33 Do you wish to include Personal Accident cover for Un-
named Passengers / hirer /pillion passengers (Two – Yes ☐ No ☐
Wheelers)?
If Yes, give number of persons and Capital Sum Insured
(CSI) opted
No. of Persons :___________________ C.S.I. (per person):_______________
Note: - The Maximum CSI available per person is ₹ 1 Lakhs in case of Motorized Two Wheelers & ₹ 2 Lakhs in case of other classes
of vehicles.
Geographical Extension (IMT-1)
34 Whether extension of geographical area to the following countries required :
1 Bangladesh Yes ☐ No ☐ 4 Maldives Yes ☐ No ☐
2 Bhutan Yes ☐ No ☐ 5 Pakistan Yes ☐ No ☐
3 Nepal Yes ☐ No ☐ 6 Sri-Lanka Yes ☐ No ☐
Note: - Presently the territory covered is geographical area of India. Extension of geographical are cover can availed by use of this
endorsement
35 Previous History
a) Date of Purchase of the vehicle by the Proposer _________________
b) Whether the vehicle was new or second hand at the time of New ☐ Second Hand ☐
purchase?
c) Will the vehicle be used exclusively for :
i) Private, Social, Domestic, Pleasure & Professional Purpose? Yes ☐ No ☐
ii) Carriage of goods other than samples or personal luggage? Yes ☐ No ☐
d) Is the vehicle in good condition? Yes ☐ No ☐
If No, please give details.
e) Name and Address of the previous insurance company
f) Previous Policy Number

Motor Proposal Form- Commercial Vehicle Page 4 of 11

IFFCO TOKIO General Insurance Company Limited. CIN: U74899DL2000PLC107621, IRDA Reg No.106
 g) Period of Insurance From To
h) Claims lodge during the preceding 3 years.
Year No of Claims Claim Amount (₹)

i) Type of Cover Liability only Package Cover ☐ Others (Specify)

Cover ☐
36 Details of Driver
a)Age and Date of Birth of the Owner Age ☐☐ D.O.B. ☐☐☐☐☐☐☐☐
b) Age and Date of Birth of other than Owner Age ☐☐ D.O.B. ☐☐☐☐☐☐☐☐
c) Does the driver suffer from defective vision or hearing or any Yes ☐ No ☐
physical infirmity?
If ‘Yes’, give details as under including the pending prosecutions:
d) Has the driver ever been involved / convicted for causing and Yes ☐ No ☐
accident of loss:
Driver’s Name
Date of Accident
Loss/ Cost ₹
Circumstances of Accident
37 Has any Insurance Company ever:-
a) Declined the Proposal Yes ☐ No ☐
b) Cancelled & Refused to renew Yes ☐ No ☐
If ‘Yes’ , reasons there for
c) Imposed special condition or excess Yes ☐ No ☐
If ‘Yes’ , reasons there for
Own Damage Section
38 Whether vehicle belongs to Foreign Embassy / Consulate? Yes ☐ No ☐
39 Whether Vehicle is designed for use of Blind/ Handicapped / Yes ☐ No ☐
Mentally challenged persons and duly endorsed as such by RTA?
40 Whether the vehicle is fitted with fiberglass tank? Yes ☐ No ☐
41 Are you entitled to No Claim Bonus? Yes ☐ No ☐
If Yes, please submit the proof thereof.
42 Is the vehicle fitted with the any Anti-theft device approved by the
AARI? Yes ☐ No ☐
If Yes, attach Certificate of Installation in the vehicle issued by
Automobiles Association if India.
43 Insured’s Declared Value (Please fill up the following table)
Insured’s Declared Non- electrical Electrical & Side Car (Two Value of CNG/LPG Total Value
Value of Vehicle accessories fitted electronic Wheeler) Trailers Kit
to the vehicle accessories fitted
to the vehicle
₹ ₹ ₹ ₹ ₹ ₹
Note:-
The Insured’s Declared Value (IDV)of the vehicle will be deemed to be the ‘SUM INSURED’ for the purpose of this product it will be
fixed at the commencement of each policy period for each insured vehicle.

The IDV of the vehicle is to be fixed on the basis of manufacturer’s listed selling price of the brand and model as the vehicle proposed
for the commencement of insurance / renewal , and adjusted for depreciation (as per schedule specified below).
The IDV of the side car(s) and/ or accessories , if any , fitted to the vehicle but not included in the manufacturer’s listed selling price of
the vehicle is / are also likewise to be fixed.

The schedule of age-wise depreciation as shown below is applicable for the purpose of Total Loss / Constructive Total Loss (TL/CTL)

Motor Proposal Form- Commercial Vehicle Page 5 of 11

IFFCO TOKIO General Insurance Company Limited. CIN: U74899DL2000PLC107621, IRDA Reg No.106
 only. A vehicle will be considered to be a CTL where the aggregate cost of retrieval and / or repair of the vehicle subject to terms and
conditions of the policy exceeds 75% of IDV.

SCHEDULE FOR DEPRECIATION FOR ARRIVING AT IDV

AGE OF THE VEHILCE % OF DEPERECIATION FOR FIXING IDV
Not exceeding 6 months 5%
Exceeding 6 months but not exceeding 1 year 15%
Exceeding 1 year but not exceeding 2 years 20%
Exceeding 2 years but not exceeding 3 years 30%
Exceeding 3 years but not exceeding 4 years 40%
Exceeding 4 years but not exceeding 5 years 50%
44 Any other Relevant Information

Availability of the following Add-on coverages is subject to the prevailing Underwriting guidelines of IFFCO-Tokio
Add-on Covers
45 Please tick the required Add-on & fill the relevant field (wherever applicable) only
(Add-on name wise UINs are mentioned in annexure)
1 Nil Depreciation cover/ Depreciation Waiver ☐ Yes ☐ No

If Yes, kindly select the coverage:

1 claim* ☐ 2 claims* ☐ No limit** ☐
*Nil Depreciation Cover
** Depreciation Waiver

2 New Vehicle Replacement ☐ Yes ☐ No

3 Personal Effect & Belongings ☐ Yes ☐ No
If Yes , Sum Insured ₹_____________________
4 Medical Expense ☐ Yes ☐ No
If yes, please mention the limit for anyone person in the multiples
of Rs. 50,000 for all Vehicles except Two/Three Wheelers where it
will be in the multiples of Rs. 25,000.

Limit Any Person:- ₹ ________________

i). Please note that the total limit for all insured person will
be twice the limit for anyone person in respect of Private
Cars, same limit as that of anyone person for Two
Wheelers and Three Wheelers and three times the limit
for anyone person in respect of all other Commercial
Vehicle
If you want the coverage on named basis, please
mention the name of insured persons and the limit
chosen against that person in the same multiples as
above:
Name of Insured Person Limit Any Person
a) ____________________ _______________
b) ____________________ ________________
c) ____________________ _________________
d) ____________________ _________________

5 Personal Accident Coverage Yes ☐ No ☐

(If Yes, please Indicate whether you would like to go with)
a) Do you want Coverage only for owner driver? Yes ☐ No ☐

Motor Proposal Form- Commercial Vehicle Page 6 of 11

IFFCO TOKIO General Insurance Company Limited. CIN: U74899DL2000PLC107621, IRDA Reg No.106
 If Yes CSI for Owner Driver _________________

b) If you want coverage for all passengers as per seating capacity

of the vehicle, then please mention the Capital Sum Insured for
insured person in the multiples of ₹ 25,000/- for Two Wheelers /
Three Wheelers and ₹ 50,000/- for other vehicles.

c)The total CSI (Capital Sum Insured) for all insured person will
the limit anyone person multiplied by the total number of seats in
the vehicle as per Registration Certificate.
i)Sum Insured for Any person ₹_____________
ii) Seating capacity _____________
iii) Capital Sum Insured for All persons ₹ ____________

6 No Claim Bonus (NCB)Protection Yes ☐ No ☐

Please mention the existing NCB %
7 Increased Property Damage Liability Benefit Yes ☐ No ☐
If Yes , Please mention the limit of excess of limit available under
Standard Motor Package Policy in respect of, liability to third party
property damage in accordance with Section-II , Liability to Third
Parties .
The limit will be given in the multiples of ₹ 1 Lac.
Limit ₹________________
8 Wreckage / Debris Removal Cost Yes ☐ No ☐
9 Loss of Income or Vehicle Hire Cost Yes ☐ No ☐
(If Yes, please Indicate whether you would like to go with)
Prefixed limit in accordance with IDV of your insured vehicle ☐
Type/Class of the Vehicle Daily Hiring Charges*
Three Wheelers (Goods Carrying ₹500 or 1% of the IDV
and Passenger Carrying Vehicles) whichever is lower
₹ 3000 or 0.5% of the IDV
Taxis whichever is lower
₹ 3000 or 0.50% of IDV
Buses whichever is lower
Goods ₹2500 or 0.50% of the IDV
Carrying Upto 25000 Kg whichever is lower
Vehicles ₹4,000 or 0.50% of IDV
Beyond 25000 kg whichever is lower
₹5000 or 0.50% of the IDV
Miscellaneous class ‘D’ Vehicles whichever is lower
As opted by you but not
Any Commercial Vehicle covered exceeding 1.0% of IDV
in Standard Commercial Vehicle ₹____________
package policy.
* The limit for Daily Rental/Travel Cost is for each 24 hours.
10 Towing and/ or Removal and Storage of the Insured vehicle Yes ☐ No ☐
11 Accommodation and Travelling Expenses Yes ☐ No ☐
12 Transport, Redelivery or Repatriation of Repaired Vehicle Yes ☐ No ☐
13 Engine and Gear Box Protection cover Yes ☐ No ☐
14 Consumable cover Yes ☐ No ☐
15 Loss of Key cover Yes ☐ No ☐
16 Full Coverage for Lamps,Tyre/Tube, Mudguards, Bonnet/Side Yes ☐ No ☐
Parts, Bumper,Head Gear and Paint Work of Damaged Portion of
Commercial Vehicles
17 RIM Protection Cover Yes ☐ No ☐
If Yes, Does the vehicle have the original RIM as supplied by

Motor Proposal Form- Commercial Vehicle Page 7 of 11

IFFCO TOKIO General Insurance Company Limited. CIN: U74899DL2000PLC107621, IRDA Reg No.106
 the Manufacture (s) As OE fitment. Yes No
18 Equated Monthly Installment (EMI ) Protection Yes ☐ No ☐
If Yes, please select the option you want.
Table A: Passenger Carrying Vehicle (Two Wheeler (C4) / Four Wheeler (C1A, C2- 7 to 10 Passenger)
EMI payment schedule based on the number Please Select
Max No of EMIs
Options Time Excess of days the vehicle is under repair at the Option you
payable
authorized garage/workshop want
I. 7 days 1 1 EMI at > 8 days ☐
1st EMI at 8-30 days ☐
II. 7 days 2
2nd EMI at > 31 days
1st EMI at 8-30 days ☐
III. 7 days 3 2nd EMI at 31-60 days
3rd EMI at > 61 days
IV. 10 days 1 1 EMI at > 11 days ☐
1st EMI at 11-30 days ☐
V. 10 days 2
2nd EMI at > 31 days
1st EMI at 11-30 days ☐
VI. 10 days 3 2nd EMI at 31-60 days
3rd EMI at > 61 days
VII. 15 days 1 1 EMI at > 16 days ☐
1st EMI at 16-30 days ☐
VIII. 15 days 2
2nd EMI at > 31 days
1st EMI at 16-30 days ☐
IX. 15 days 3 2nd EMI at 31-60 days
3rd EMI at > 61 days
X. 30 days 1 1 EMI at > 31 days ☐
1st EMI at 31-60 days
XI. 30 days 2
2nd EMI at > 61 days
1st EMI at 31-60 days
XII. 30 days 3 2nd EMI at 61-90 days
3rd EMI at > 91 days
Table B: All Other Commercial Vehicles (Expect Vehicle Covered Under Table A)

EMI payment schedule based on the number Please Select

Max No of EMIs
Options Time Excess of days the vehicle is under repair at the Option you
payable
authorized garage/workshop want
I. 30 days 1 1 EMI at > 31 days
1st EMI at 31-60 days
II. 30 days 2
2nd EMI at > 61 days
1st EMI at 31-60 days
III. 30 days 3 2nd EMI at 61-90 days
3rd EMI at > 91 days
IV. 45 days 1 1 EMI at > 46 days
1st EMI at 46-60 days
V. 45 days 2
2nd EMI at > 61 days
1st EMI at 46-60 days
VI. 45 days 3
2nd EMI at 61-90 days

Motor Proposal Form- Commercial Vehicle Page 8 of 11

IFFCO TOKIO General Insurance Company Limited. CIN: U74899DL2000PLC107621, IRDA Reg No.106
 3rd EMI at > 91 days
VII. 60 days 1 1 EMI at > 61 days
1st EMI at 61-90 days
VIII. 60 days 2
2nd EMI at > 91 days
1st EMI at 61-90 days
IX. 60 days 3 2nd EMI at 91-120 days
3rd EMI at > 121 days

19 Road Side Assistance Cover Yes ☐ No ☐

☐ Cheque ☐ DD ☐ NEFT
Mode of Payment
Instruments No Instruments No UTR No.
Bank Name Date
Bank A/C number (#) IFSC Code:
Amount (in ₹)

# Bank Account Details For Process Of Refund/ Settlement of claim

All settlements for Refund/Claims shall be made in the bank account whose details are provided below
Please provide the following bank details and a copy of Cancelled Cheque for direct credit of refund/ claim into your bank account :( Cancelled
Cheque should be of the same bank account in which the refund/ claim proceeds needs to be credited directly.)

Name as in Bank Account

Bank Name

Branch Name

Bank Account No

IFSC Code

DECLARATION
a) I have read the prospectus/sales literature and am willing to accept the coverage subject to the terms, conditions and exceptions
prescribed by IFFCO-Tokio therein. The policy Coverage, Rates, terms & Conditions have been explained to me in my language and
have been understood by me.

b) I hereby declare and warrant that the above statements are true and complete in all respects and that there is no other information,
which is relevant to my application for insurance that has not been disclosed to you. I agree that this proposal and the declaration shall
be the basis of the contract between me and IFFCO TOKIO GENERAL INSURANCE CO LTD and I agree to accept a policy, subject
to the conditions prescribed by IFFCO TOKIO GENERAL INSURANCE CO LTD.

c) I agree that the Policy shall become voidable at the option of the Company, in the event of any untrue or incorrect statement,
misrepresentation, non- description or non-disclosure of material particulars in the Proposal Form/ personal statement, declaration
and connected documents, or any material fact*/ information has been withheld by beneficiary

*A material fact will mean and include all important, essential and relevant information, pertaining to the questions made in this
proposal form, that are likely to influence company's acceptance or assessment of the proposal

d) I hereby authorize IFFCO-Tokio to share information on my proposal for the sole purpose of evaluating and underwriting this proposal
and issuing insurance policy and/or claims settlement Surveyors/ Investigators .with the Reinsurers/Co-Insurers, Regulatory and or
Governmental Authorities/Court under the applicable laws, or as may be required for effective discharge of obligations as an Insurer

Motor Proposal Form- Commercial Vehicle Page 9 of 11

IFFCO TOKIO General Insurance Company Limited. CIN: U74899DL2000PLC107621, IRDA Reg No.106
 and I understand that this proposal form is a valid consent from my side for sharing my personal data with above named third parties
in connections or furtherance of this policy/claim.

e) I am submitting my Aadhar Card/Aadhar Number (including Virtual ID, e-Aadhaar) voluntarily for KYC and I understand that use of
Aadhaar is not mandatory and alternative documents like Voter ID Card/ Passport/ Driving License/ NREGA Job card/ National
Population Register Card/ CKYC Number may also be submitted for KYC. I hereby further authorize IFFCO-TOKIO to
download/update/upload my particulars from/to CKYC Registry, based on CKYC no./ Other KYC documents provided by me.

f) AML Guidelines - 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 crime related to any of the offence listed in Prevention of Money Laundering Act 2002. I/We
understand that the Company has the right to call for documents to establish source of funds. The insurance Company has the right to
cancel the insurance contract in case I am/ have been found guilty by any competent court of law under any statues, directly or
indirectly governing the prevention of money laundering in India.

g) Vernacular Declaration
Applicable where the Proposer is illiterate or is suffering from a disability due to which writing is restricted or where the Proposer has
signed in vernacular language. (Note: The below must be witnessed by someone other than the Agent/ Intermediary/Employee of the
Company).

l certify that the product applied by me and the contents of the Proposal Form have been clearly explained to me and l have fully
understood them. l further certify that the replies in the Proposal Form have been recorded as per the information provided by me.

h) I agree that above-mentioned bank account details (#) may be used for the purpose of refund/ settlement of Claims (applicable for
those cases where “Agreed Bank Clause” is not opted under this policy).

I agree IFFCO-Tokio to call, and send SMS, messages over internet-based messaging applications like WhatsApp and e-mail for
services related to the product and to also offer additional insurance products and this consent is over and above any registration of
the contact number on TRAI’s National Do Not Call Registry.

I have not having vehicle registration no at present and I agree to provide the same within _____ months of issuance (Applicable for
New Vehicle only).

Date :---------------------------------- Signature:_____________

Place: -------------------------------------- Name of the Proposer

Witness Declaration:
I_______________________(Full name of the witness)_____________________________________(Relation with the Proposer)
adult and inhabitant of (city)___________ and residing at__________________________ do hereby certify that I have read out and
explained the contents of the Proposal Form and all other documents incidental to availing the insurance policy from IFFCO-Tokio
General Insurance Co. Ltd. to the Proposer and he/she has understood the same. l declare that whatever l have stated herein above
is true and correct to the best of knowledge and belief.

Witness Signature: _____________

Place: -------------------------------------- Name of Witness:__________

Motor Proposal Form- Commercial Vehicle Page 10 of 11

IFFCO TOKIO General Insurance Company Limited. CIN: U74899DL2000PLC107621, IRDA Reg No.106
PROHIBITION OF REBATES SECTION 41 OF THE INSURANCE ACT 1938 PROVIDES AS FOLLOWS:

1. 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 of any 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 the policy ,nor shall any person taking out or renewing a policy accept any rebate ,except such rebate
as may be allowed in accordance with the published prospectus or tables of the insurer.

2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh
rupees.

Annexure

S.No. Product Name UIN

1 IRDAN106RP0005V01200607/A0017V01202223
Commercial Vehicle - Package policy/Add-on: Engine and Gear Box Protection Cover
2 Commercial Vehicle - Package policy/Add-on: Consumable Cover IRDAN106RP0005V01200607/A0018V01202223
3 Commercial Vehicle - Package policy/Add-on: Loss of Key IRDAN106RP0005V01200607/A0016V01202223
4 Commercial Vehicle - Package policy/Add-on: Full Coverage for Lamps,Tyre/Tube, Mudguards, IRDAN106RP0005V01200607/A0015V01202223
Bonnet/Side Parts, Bumper,Head Gear and Paint Work of Damaged Portion Of Commercial
Vehicles
5
Equated Monthly Installment (EMI) Protection for Commercial Vehicle Package Policy IRDAN106RP0005V01200607/A0039V01202223
6 Rim Protection Cover for Commercial Vehicle Package Policy IRDAN106RP0005V01200607/A0043V01202223
7 Nil Depreciation Cover for Commercial Vehicle Package Policy IRDAN106RP0005V01200607/A0008V01202425
8 Road Side Assistance Cover for Commercial Vehicle Package Policy
IRDAN106RP0005V01200607/A0012V01202425

S No. Product Name Coverage Name UIN

1 Depreciation Waiver
2 New Vehicle Replacement
3 Personal Effect and Belongings
4 Medical Expenses
5 Personal Accident Coverage
6 Value Auto Coverage No Claim Bonus (NCB) Protection IRDAN106A0015V01200910
7 Increased Property Damage Liability Benefit
8 Wreckage/Debris Removal Cost
9 Loss of Income or Vehicle Hire Cost
10 Towing and/or Removal/Storage of the Insured Vehicle
11 Accommodation and Travelling Expense
12 Transport, Redelivery or Repatriation of Repaired Vehicle

Motor Proposal Form- Commercial Vehicle Page 11 of 11

IFFCO TOKIO General Insurance Company Limited. CIN: U74899DL2000PLC107621, IRDA Reg No.106