The New India Assurance Company Limited 
                    Head Office: 87, M G Road, Fort, Mumbai-400001 
                       
          PROPOSAL FORM DOG INSURANCE (CANINE INSURANCE) 

SCOPE OF SCHEME: Dogs are insured against death due to accident and/or diseases contacted during the period of insurance subject to usual terms, conditions and exclusions of policy.

A.	Insured’s Name: ______________________________________________________

B.	Insured’s Address: _____________________________________________________
     
       _____________________________________________________
   
C.	Date of Proposal & Declaration: __________________________________________

D.	Description of the dog/s:

(1)	Total No. of dogs__________________________________________________ 

(2)	No. of the dogs per unit: ___________________________________________

(3)	Identification: ___________________________________________________

(4)	Variety of type of dogs: ___________________________________________

(5)	Date of purchase: ________________________________________________

(6)	Source of purchase: ______________________________________________

(7)	Age of dogs covered: _____________________________________________   

E.	SUM INSURED Rs. _____________________________________________

F.	Location of the place where the dogs are housed /kenneled: __________________

G.	Vaccination particulars: _______________________________________________

H.	Any other information: _______________________________________________

I/WE hereby propose to insure the abovementioned dog/s owned by me/us with THE NEW INDIA ASSURANCE CO. LTD. subject to the terms, conditions and exclusions of the Company’s policy.

I/WE warrant that the answers to the above queries are true and that all the dog/s are correctly described are sound, in good health and free from vice. I/WE declare that no information material to the insurance has been withheld and agree that this proposal shall be the basis of the contract between me/us and the Company.

Date: _______________     					____________________

Place: ______________					         Signature of the proposer