Janata/Gramin Personal Accident Insurance
Proposal Form

FOR OFFICE USE Agency:  178 / Mrs. K.Yamini     Dev Officer Code : 108 / Mr. Suresh Branch:  Ameerpet, Hyderabad.  Policy No .................................       Receipt No ..............................

1.Proposers Name(infull)  ...............................................................................................................

2.Address(infull)  ...........................................................................................................................

3.Occupation .........................................

4.Age in years ................  Date of Birth ..............................

5.Name of Nominee (in full) ........................................................Age ............ Years .......................

Signature(if available) .....................................................................................................................

6.Address(infull)..............................................................................................................................

7.Relationship with Proposer..............................................................................................................

8.Nomination witnessed by 1) ...........................................................................................................

                                        2) ...........................................................................................................

9.Insurance required : From ..................................................... To .....................................................

10.Average monthly income Rs.......................

11.Sum Insured :......................

12. Premium Rs. ..............

13.Whether you have taken any other JPA Insurance ,if Yes,
(Please note that one person should not be given more then one policy and the maximum Sum Insured is restricted
to 1,00,000/- per person ).................................................

14.If you have already lost eye sight or limbs ,Please give details: ........................................................................

                               I hereby declare and warrant that the above statements are true. I desire to effect an insurance as described herein and agree that this proposal and declaration shall be the basis of the contract between me and the company I agree to accept a policy as prescribed by the company.