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    Driver Questionnaire PDF

    Uploaded by

    Aman Trivedi
    This document is a driver questionnaire for an insurance policy. It collects information about the applicant such as the type of vehicle driven, total daily distance traveled, type of goods carried if driving a truck or container, and any history of accidents. The applicant must sign to declare that their answers are truthful and complete. If the applicant cannot read, a witness must verify that the contents were explained to the applicant in their language.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Driver Questionnaire PDF

    Uploaded by

    Aman Trivedi
    722 views2 pages
    This document is a driver questionnaire for an insurance policy. It collects information about the applicant such as the type of vehicle driven, total daily distance traveled, type of goods carried if driving a truck or container, and any history of accidents. The applicant must sign to declare that their answers are truthful and complete. If the applicant cannot read, a witness must verify that the contents were explained to the applicant in their language.

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    Driver Questionnaire.pdf

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    This document is a driver questionnaire for an insurance policy. It collects information about the applicant such as the type of vehicle driven, total daily distance traveled, type of goods carried if driving a truck or container, and any history of accidents. The applicant must sign to declare that their answers are truthful and complete. If the applicant cannot read, a witness must verify that the contents were explained to the applicant in their language.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    722 views2 pages

    Driver Questionnaire PDF

    Uploaded by

    Aman Trivedi
    This document is a driver questionnaire for an insurance policy. It collects information about the applicant such as the type of vehicle driven, total daily distance traveled, type of goods carried if driving a truck or container, and any history of accidents. The applicant must sign to declare that their answers are truthful and complete. If the applicant cannot read, a witness must verify that the contents were explained to the applicant in their language.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Driver Questionnaire

    Name of Proposed Insured: .............................................................................................................................


    Policy no.: ....................................................................................... Dated:................................................

    1) Type of vehicle driven (Tick where applicable)


    TYPE YES NO Approximate KMS/Day

    CAR

    BUS

    TRUCK

    CONTAINER

    CRANE

    OTHERS

    2) If others, then please specify the type


    ........................................................................................................................................................

    3) Total distance covered in a day:

    <100 kms 100-200 kms >200 kms

    4) If Truck/Container, then, please specify whether carries (Tick where applicable)

    Type of Goods carried YES NO

    Hazardous/Explosive Goods

    Non-Hazardous/Non-explosive Goods

    5) Any history of accident while driving? If yes, please provide details with respect to severity of
    accident and hospitalization/injury details.
    ........................................................................................................................................................

    Tata AIA Life Insurance Company Limited


    .(IRDA of India Regn. No. 110) CIN - U66010MH2000PLC128403
    Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
    For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
    Unique Reference Number L&C/Misc/2014/Oct/280
    I declare that the answers I have given are, to the best of my knowledge, true and I have not withheld any
    material information that may influence the assessment of acceptance of this proposal.
    I agree that this form will constitute part of my proposal for life assurance and that failure to disclose any
    material fact known to me may invalidate the contract.

    Signature of Proposed insured:______________________ Date:____________________

    Signature of Applicant:______________________ Date:____________________


    (If applicant is different from the proposed insured)

    VERNACULAR DECLARATION:
    In case the Proposed Insured/Applicant affixes a thumb impression or signs in vernacular.

    I__________________ holding ______________(ID card type) with number __________(ID card


    number) hereby declare that I have explained the contents of this declaration to the Proposed
    Insured/Applicant in ________________ language and that the Proposed Insured/Applicant has affixed
    his/her signature/thumb impression after fully understanding the contents thereof.

    ________________________________ _____________________
    Signature/Thumb Impression of Proposed Insured/Applicant Witness Signature

    Tata AIA Life Insurance Company Limited


    .(IRDA of India Regn. No. 110) CIN - U66010MH2000PLC128403
    Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
    For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
    Unique Reference Number L&C/Misc/2014/Oct/280

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