The New India Assurance Company Limited 
                    Head Office: 87, M G Road, Fort, Mumbai-400001 
                  
               PROPOSAL FORM FOR STUDENT SAFETY INSURANCE     

1.	Name of the Institution: _______________________________________________
(in Block letters)
     
2.	Address: ____________________________________________________________

3.	Number of Students as on date: _________________________________________

Discipline: __________________________________________________________

4.	Period of Insurance: __________________________________________________

5.	Limit of Compensation       : ____________________________________________ 
Selected for any one year
 
a)	for any one student: ____________________________________________

b)	for any one accident: ____________________________________________

c)	for any one year: _______________________________________________

    I declare that the above answers are true to the best of our knowledge and belief that we have disclosed all the particulars effecting the assessment of the risk. We agree that the proposal and declaration shall be the basis of the contract between us and the company. Further, it is also declared that proper attendance register is being maintained throughout giving the names of all the students studying in the school.

Date: ___________  			          ____________________________

Place: ___________ 					   Signature of the proposer