The New India Assurance Company Limited 
                    Head Office: 87, M G Road, Fort, Mumbai-400001 
                       
                         JAN AROGYA BIMA POLICY PROPOSAL FORM

AGENCY CODE: ____________    DEV. OFFICER CODE: ________________

POLICY NO.: _______________   ANNUAL PREMIUM RS.________________

IMPORTANT: The Company will not be on risk until the Proposal has been accepted by the Company and the premium paid in full.
 
				   PROPOSER DETAILS 

1.	Name of Proposer: ______________________________________________

2.	Address: _________________________________________________________

                   ____________________________________PIN__________________

3.	Details of the persons to be insured (Self/ Spouse/Son/Daughter)

 
Name of the Insured Person 	Age	Sex	Occupation	Relationship
With the Insured	Details of pre-existing diseases/ illness if any	Premium
(Rs.)	

							

4.	Period of Insurance: From _________________ to ___________________(midnight)

I/We, hereby declare that the information furnished above are true and correct to my / our knowledge and belief. I/We, also declare that, I/We, am/are sound in health and am/are devoid of any disease/illness.

Place: ____________					_______________________

Date: