UFA Proposals

Motor Insurance Proposal

Introduced By:
No:
Policy No:
In case of compulsory mention No:
Effective Date: (at noon)
Expiry Date: (at noon) >

Currency
Total Premium

The Applicant

First Name
Last Name
Father
D.O.B
Marital Status
Gender
Occupation
Building
Street
City
Region
Phone No.

Insured Vehicle Specifications

Make
Seats
Year
H.P
Type
Usage
Plate No.
Engine No.
Chassis No.

Particular Conditions

A) Third Party Liability
Bodily Injury
Material Damage
Passengers
Driver
B) Own Damage
C) Fire Of The Vehicle
D) Theft Of The Vehicle
E) Territorial Limit
N:B
A copy of the car registration document is required. No insurance is in force until the Proposal has been accepted by the company, and the Premium or a deposit paid except as provided by an official covering note issued by the company.