THE NEW INDIA ASSURANCE POLICY No.

COMPANY LTD.

(Incorporated in India)

Motor Vehicles (Third Party Insurance)

Ordinance, Fiji

A World Wide Company PROPOSAL FORM

Agent or Agency

NAME OF REGISTERED OWNER

ADDRESS

OCCUPATION

If married woman, state occupation

of husband.

PERIOD OF POLICY

From ______20 ______to 4 p.m on ______20______

  • In case of Indians, state Father’s name also

I/We hereby apply for insurance under the provisions of the Motor Vehicles (Third Party Insurance)

Ordinance against liability in respect to the death of or bodily injury to any person caused by or arising

out of the use of Motor referred to in the Schedule hereto.

PARTICULARS OF MOTOR VEHICLE TO WHICH INSURANCE IS LIMITEDPREMIUM $______

Make of Motor Vehicle, Type of If used for the carriage of goods, Year of Engine Chassis Registered

Motor Cycle or TrailerBody state Licenced Carrying Capacity Manufacturer Number Number Number

…………….tons……………..cwt

1. State clearly all purpose for which the Motor Vehicle will be used ______

2. Does the Certificate of Registration or Licence for the Motor Vehicle bear any endorsement or condition-

(a) Restricting the use of the vehicle to certain specified persons only? ______

(b)In the case of a Goods Vehicle, is there any authorization held under Reg. 54 of the Traffic regulations, 1967 permitting the carriage of excess

passengers? If so, state (i) the number of passengers so authorized and (ii) the purpose for which the vehicle is to be used under the authorization,

(i)______(ii) ______

3. State item number of Motor Vehicle for purpose of Insurance. See back hereof for Schedule of vehicles ______

4. Will the Motor Vehicle be used fro the conveyance of passengers for hire, fare or reward? ______

5. (a) Is the Motor Vehicle already insured under a Comprehensive policy or otherwise? ______

(b) If so, state particulars and names of Insurer ______due date ______

6. Have you and/or your paid driver and/or any person who drives or who to your knowledge is likely to drive the vehicle-

(a)Secured the necessary licence to drive? ______

(b)Ever had the licence endorsed or cancelled or been convicted for an offence in connection with a Motor Vehicle? If so, give particulars

______

(c) Ever been convicted for drunkenness? If so, give particulars ______

(d) Ever had an accident to a Motor Vehicle? If so, give full details of every occurrence ______

(e) Made a claim under any Motor Vehicle Insurance policy? If so, state dates and names of each Insurer claimed upon ______

______

(f) Defective vision or hearing or any physical defect or infirmity? If so, give particulars ______

(g) Ever suffered from a fit of any kind? ______

(h) Ever been refused Motor Vehicle Insurance or continuance thereof by any insurer? If so, give particulars ______

______

(i) Ever had an excess or franchise imposed on a policy of Insurance? If so, give particulars ______

7. Give name of Company transacting your Fire and Accident Insurances ______

ALL QUESTIONS NOT ANSWERED SHALL BE DEEMED TO BE ANSWERED IN THE NEGATIVE

I/We do hereby declare and warrant that the answer and particulars given above are in every respect true and correct and that I/We have not withheld any information likely to affect the acceptance of this application and I/We agree that this application and declaration shall be of the contract between the company and myself/ourselves.

Date ______200______Poposer’s Signature ______

CERTIFICATE BY WITNESS WHERE PROPOSER DOES NOT UNDERSTAND ENGLISH. IF COMPANY PUT COMPANY SAEL

I certify that, before the Proposer’s execution of this document, I read over and explained it to him in the Fijian and/or Hindi language, when he/she appeared to fully understand the maning and effect thereof.

Signature______

MOTOR VEHICLES (THIRD PARTY) CLASSIFICATION

Item No.CLASS OF VEHILE
  1. PRIVATE CAR. A motor car which is used solely

(a)For social, domestic or pleasure purposes, or

(b)By the owner, being an individual, for his own carriage in relation to his profession,

business or calling, provided that profession, business or calling is not that of a

commercial traveler or traveling salesman or an insurance agent, inspector or

assessor, or an indent or manufacturer’s agent.

  1. BUSINESS CAR.A motor car used for business purposes and not included in classes

1, 3, 4 5, 6, 9, and 10. For the purpose of this definition the performance by Government

or a local authority of any of its functions shall be deemed to be the carrying on of a

business.

  1. GOODS VEHICLE. A motor vehicle, which is constructed or adapted or primarily used

For the conveyance of goods or merchandise of any description in connection with trade,

Business or agriculture. For the purposes of this definition the performance by

Government of local authority of any of its functions shall be deemed to be the carrying

On of a business.

(a)Light goods vehicle with a carrying capacity of up to 2 tons.

(b)Light goods vehicle as in (a) authorized under regulation 54 of the Traffic

Regulations, 1967, to carry excess passengers.

(i)Carriage of up to and including eleven passengers.

(ii)Carriage of more than eleven passengers.

(c) Heavy goods vehicle with a carrying capacity of over 2 tons.

(d) Heavy goods vehicles as in (c) authorized under regulation 54 of the traffic

Regulation, 1967, to carry excess passengers.

(i)Carriage of up to and including eleven passengers.

(ii)Carriage of more than eleven passengers.

  1. TAXI (being a public service vehicle licensed and used for carrying not more than 6

Passengers for hire or reward) or HIRE CAR licensed as such and used for letting on

Hire with a driver.

  1. OMNIBUS A motor vehicle licensed and used for carrying more than 6 passengers

For hire or reward.

(a) Vehicle having a seating capacity of not more than 11 passengers.
(b) Vehicle having a seating capacity of more than 11 passengers.

  1. FIRE BRIGADE VEHICLE, AMBULANCE, POLICE VEHICLE AND PRISON VEHICLE

VEHICLE (including Police and Fire Brigade motor cycles.)

  1. MOTOR CYCLE. A motor vehicle designed to travel on not more than 3 wheels and

The net weight of which does not exceed 5 hundred weight, for whatever purposes

Used, other than as Police and Fire Brigade motor cycles.

  1. TRAILERS. For whatever purposes used.

9. MOTOR TRADE VEHICLES-

(a)A motor vehicle or motor cycle to which plates in respect of a dealer’s general

Licence issued under section 20 of the Traffic Ordinance are affixed and which

Is used in compliance with the regulations made under the said Ordinance in

Respect of such a licence.

(b)A motor breakdown ambulance.

10. RENTAL CARS licensed as such and used for letting on hire without a driver.

11. MISCELLANEOUS VEHICLE NOT OTHERWISE CLASSIFIED

(e.g. Tractors, Hearses, Road Rollers, Mobile Cranes, Road Graders, etc.)

NOTE 1 PREMIUM FOR TERM PERIOD- where the insurance is for any period of

Less than one year, the premium is calculated at the rate of one-twelth of

The annual premium for each month or part thereof, however, such amount

shall not be less than the minimum premium of $25.00

NOTE 2 PREMIUM FOR CANCELLATION- where the policy is cancelled the return

Premium shall be calculated PRO RATA less ten per cent, subject to the

Minimum premium being retained by the insurer.