{"id":2770,"title":"THIRD-PARTY LONG-TERM TWO-WHEELER INSURANCE POLICY- 5 YEARS PROPOSAL FORM","purpose":"proposal","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/motor-insurance/third-party-long-term-two-wheeler-insurance-policy-5-years/proposal-forms/third-party-long-term-motor-two-wheeler-insurance-policy-5-years-proposal-form.pdf","sha256":"f191231ed1c2f0f107e11a9b92631bb438cb1566746120ae5482325357eedb81","pages":9,"collected":"2026-10-17","instructions":{"about":"This form is used by the proposer/owner to apply for a third-party long-term two-wheeler insurance policy for 5 years with Generali Central Insurance Company Limited.","notes":["Insurance is a contract of utmost good faith; all material facts must be disclosed.","Answer all questions; attach separate signed and dated sheet if more space is needed.","Cover starts only after acceptance and receipt of premium.","Copies of R.C. & Fitness Certificate must be submitted with the proposal form.","Personal Accident cover for Owner Driver is compulsory with minimum sum insured of Rs. 15,00,000 for two wheelers.","Compulsory PA cover not granted if vehicle owned by company/firm or owner-driver lacks valid driving license.","Use block letters for filling the form.","The company may reject proposal or terminate contract if proposer or associated persons are on any blacklist.","For premium above Rs. 10,000, fill authorization form to receive claim/refund payments via NEFT.","Physical copy of policy document can be requested by ticking the box; otherwise digital copy will be sent."],"title":"THIRD-PARTY LONG-TERM TWO-WHEELER INSURANCE POLICY- 5 YEARS PROPOSAL FORM","submit":{"to":"","how":"","address":""},"purpose":"proposal","sections":[{"title":"Personal Details of Proposer/Owner","fields":[{"help":"Write your full name in capital letters.","type":"text","label":"Proposer’s (Owner’s) Full Name (In capital letters)","options":[],"required":true,"pdf_field":""},{"help":"Write your present address in capital letters including pin code.","type":"text","label":"Present Address of proposer (where the vehicle is normally kept) (In capital letters, with pin code)","options":[],"required":true,"pdf_field":""},{"help":"Enter the pin code of your present address.","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Enter your telephone number if available.","type":"phone","label":"Telephone No","options":[],"required":false,"pdf_field":""},{"help":"Enter your PAN Card or Aadhar number.","type":"text","label":"PAN Card/Aadhar","options":[],"required":false,"pdf_field":""},{"help":"Enter fax number if applicable.","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Enter your mobile number.","type":"phone","label":"Mobile No.","options":[],"required":true,"pdf_field":""},{"help":"Enter eIA if applicable.","type":"text","label":"eIA","options":[],"required":false,"pdf_field":""},{"help":"Enter your email address.","type":"email","label":"Mail Id","options":[],"required":false,"pdf_field":""},{"help":"Enter permanent address or leave blank if same as present address.","type":"text","label":"Permanent address of the proposer (if left blank, will be construed as being same as Present Address)","options":[],"required":false,"pdf_field":""},{"help":"Enter your occupation or business.","type":"text","label":"Occupation / Business","options":[],"required":true,"pdf_field":""},{"help":"Enter your CKYC number if available.","type":"text","label":"CKYC No. (if available)","options":[],"required":false,"pdf_field":""},{"help":"Tick all applicable categories.","type":"checkbox","label":"I am (please tick all that are applicable)","options":["High Net Worth Individual/s","Non-Residential Indian/s","Politically Exposed Person","Non-Governmental Organisation","Non-Profit Organisation"],"required":false,"pdf_field":""},{"help":"Provide registration number if applicable.","type":"text","label":"If you are an NGO/NPO, please provide Niti Ayog – Darpan Portal Registration Number","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No. If Yes, provide details below.","type":"yes-no","label":"If you are Differently Abled, please tick on the checkbox to provide confirmation.","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Describe type of impairment if applicable.","type":"text","label":"Type of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Enter percentage of impairment if applicable.","type":"number","label":"Percentage of Impairment","options":[],"required":false,"pdf_field":""},{"help":"Enter UDID number if applicable.","type":"text","label":"UDID Number","options":[],"required":false,"pdf_field":""},{"help":"Select the type of cover.","type":"choice","label":"Type of Cover","options":["Liability Only Policy"],"required":true,"pdf_field":""},{"help":"Enter start date and time of insurance.","type":"date","label":"Period of Insurance From","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer/owner"},{"title":"Vehicle Details","fields":[{"help":"Enter vehicle registration number.","type":"text","label":"Registration Number of the Vehicle","options":[],"required":true,"pdf_field":""},{"help":"Enter date of vehicle registration.","type":"date","label":"Date of Registration of the Vehicle","options":[],"required":true,"pdf_field":""},{"help":"Enter registering authority and location.","type":"text","label":"Registering Authority & Location","options":[],"required":true,"pdf_field":""},{"help":"Enter year vehicle was manufactured.","type":"number","label":"Year of Manufacture","options":[],"required":true,"pdf_field":""},{"help":"Enter engine number of the vehicle.","type":"text","label":"Engine Number","options":[],"required":true,"pdf_field":""},{"help":"Enter chassis number of the vehicle.","type":"text","label":"Chassis Number","options":[],"required":true,"pdf_field":""},{"help":"Enter make of the vehicle.","type":"text","label":"Make of the Vehicle","options":[],"required":true,"pdf_field":""},{"help":"Enter model of the vehicle.","type":"text","label":"Model","options":[],"required":true,"pdf_field":""},{"help":"Enter type of vehicle body.","type":"text","label":"Type of Body","options":[],"required":true,"pdf_field":""},{"help":"Enter cubic capacity of the vehicle.","type":"number","label":"Cubic Capacity of the Vehicle","options":[],"required":true,"pdf_field":""},{"help":"Enter seating capacity including driver.","type":"number","label":"Seating Capacity including driver","options":[],"required":true,"pdf_field":""},{"help":"Specify details if vehicle uses non-conventional power source.","type":"text","label":"Whether vehicle is driven by non-conventional source of power /CNG/LPG/Bi-Fuel? If ‘YES’, please give details.","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Whether the use of vehicle is limited to own premises?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Whether the vehicle is used for commercial purpose?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Whether the vehicle is used for driving tuition? (GR-44)","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Provide details if vehicle is under hire purchase, lease or hypothecation.","type":"text","label":"Details of Hire Purchase / Hypothecation / Lease (IMT-5)/(IMT-7)/(IMT-6)","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Under Lease Agreement?","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Under Hypothecation?","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Provide name and address of party if applicable.","type":"text","label":"If ‘YES’, give name and address of concerned party/parties","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer/owner"},{"title":"Liability Section: Coverage","fields":[{"help":"Tick Yes or No.","type":"yes-no","label":"Coverage for liability against Third Party Risks (Death or Bodily Injury) required in respect of: (i) Owner Driver only","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Coverage for liability against Third Party Risks (Death or Bodily Injury) required in respect of: (ii) Any person other than Paid Driver","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Do you wish to have the statutory Third-Party Property Damage (TPPD) liability of Rs. 6000/- only?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Enter number of drivers employed.","type":"number","label":"Legal liability to persons employed in connection with operation of the vehicle, who are ‘workmen’. Number of Drivers","options":[],"required":false,"pdf_field":""},{"help":"Enter number of employees/workmen employed.","type":"number","label":"Legal liability to persons employed in connection with operation of the vehicle, who are ‘workmen’. Number of Employees (Workmen)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer/owner"},{"title":"Additional Covers as per IMT Endorsements","fields":[{"help":"Tick Yes or No.","type":"yes-no","label":"Do you wish to cover wider legal liability to employees who are ‘workmen’?","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Do you wish to cover wider legal liability to employees who are NOT ‘Employees’?","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No. If yes, provide policy details.","type":"yes-no","label":"Personal Accident Cover for Owner Driver: Do you have existing CPA Cover or Personal Accident Cover","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide insurance company name if applicable.","type":"text","label":"Name of the Insurance Company","options":[],"required":false,"pdf_field":""},{"help":"Provide policy number if applicable.","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Provide sum insured amount if applicable.","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Provide policy period if applicable.","type":"text","label":"Policy Period","options":[],"required":false,"pdf_field":""},{"help":"Provide relationship to nominee.","type":"text","label":"Relationship","options":[],"required":false,"pdf_field":""},{"help":"Provide appointee name if nominee is minor.","type":"text","label":"Name of the Appointee (If Nominee is a minor)","options":[],"required":false,"pdf_field":""},{"help":"Provide relationship to nominee.","type":"text","label":"Relationship to the Nominee","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No. If Yes, provide names and sum insured.","type":"yes-no","label":"Do you wish to include Personal Accident cover for named persons?","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No. If Yes, provide number of persons and CSI per person.","type":"yes-no","label":"Do you wish to include Personal Accident cover for Un-named Passengers/hirer/pillion passengers (Two Wheelers)?","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Whether extension of geographical area to the following countries required? Bangladesh","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Bhutan","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Maldives","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Nepal","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Pakistan","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No.","type":"yes-no","label":"Sri Lanka","options":["YES","NO"],"required":false,"pdf_field":""}],"filled_by":"proposer/owner"},{"title":"Other Vehicle Related Information","fields":[{"help":"Enter date of vehicle purchase.","type":"date","label":"Date of purchase of the vehicle by the Proposer","options":[],"required":true,"pdf_field":""},{"help":"Select new or second hand.","type":"choice","label":"Whether the vehicle was new or second hand at the time of purchase?","options":["NEW","SECOND HAND"],"required":true,"pdf_field":""},{"help":"Tick Yes or No. If No, provide details.","type":"yes-no","label":"Is the vehicle in good condition?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Provide details if vehicle is not in good condition.","type":"text","label":"If NO, please give details","options":[],"required":false,"pdf_field":""},{"help":"Provide previous insurer details if any.","type":"text","label":"Name and Address of the previous insurance company","options":[],"required":false,"pdf_field":""},{"help":"Provide previous policy number if any.","type":"text","label":"Previous policy number","options":[],"required":false,"pdf_field":""},{"help":"Provide previous policy period if any.","type":"date","label":"Period of Insurance (From - To)","options":[],"required":false,"pdf_field":""},{"help":"Provide claim details for last 3 years.","type":"table","label":"Claims lodged during the preceding 3 years: YEAR, NO. OF CLAIMS, CLAIM AMOUNT (Rs.)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer/owner"},{"title":"Driver Details","fields":[{"help":"Enter age and DOB of owner.","type":"text","label":"Age and Date of Birth of the Owner","options":[],"required":true,"pdf_field":""},{"help":"Enter age and DOB of driver.","type":"text","label":"Age and Date of Birth of the Driver","options":[],"required":true,"pdf_field":""},{"help":"Tick Yes or No. If Yes, provide details.","type":"yes-no","label":"Does the driver suffer from defective vision or hearing or any physical infirmity?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Provide details of infirmity if applicable.","type":"text","label":"If ‘YES’, please give details of such infirmity","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No. If Yes, provide details.","type":"yes-no","label":"Has the driver ever been involved / convicted for causing any accident or loss?","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Provide accident details if applicable.","type":"text","label":"If ‘YES’, give details as under including the pending prosecutions: Driver’s Name, Date of Accident, Loss/ Cost (Rs.), Circumstances of Accident","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer/owner"},{"title":"Payment Details","fields":[{"help":"Specify mode of payment.","type":"text","label":"Mode of Payment","options":[],"required":true,"pdf_field":""},{"help":"Provide payment details.","type":"text","label":"Payment Details","options":[],"required":true,"pdf_field":""},{"help":"Enter amount paid.","type":"amount","label":"Amount in (Rs.)","options":[],"required":true,"pdf_field":""},{"help":"Enter date of payment.","type":"date","label":"Date of Payment (DD/MM/YY)","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN if premium is 1 lakh or above.","type":"text","label":"PAN (If premium is 1 Lac and Above.)","options":[],"required":false,"pdf_field":""},{"help":"Enter GSTIN or attach annexure if multiple.","type":"text","label":"GSTIN (If more than one GSTIN, kindly attach an annexure with details)","options":[],"required":false,"pdf_field":""},{"help":"Provide bank account holder name.","type":"text","label":"Bank details of proposer for refund or claim purpose: Name of bank account holder (mention specifically, if different from name of policyholder)","options":[],"required":true,"pdf_field":""},{"help":"Provide bank name and branch.","type":"text","label":"Bank Name & Branch","options":[],"required":true,"pdf_field":""},{"help":"Provide bank account number.","type":"text","label":"Bank Account Number","options":[],"required":true,"pdf_field":""},{"help":"Provide IFSC code.","type":"text","label":"IFS Code","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer/owner"},{"title":"Nominee Details","fields":[{"help":"Enter nominee's name.","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's date of birth.","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Enter relationship with proposer.","type":"text","label":"Relationship with the proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter nominee's mobile number.","type":"phone","label":"Mobile Number","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's email address.","type":"email","label":"E-Mail ID","options":[],"required":false,"pdf_field":""},{"help":"Enter nominee's present address.","type":"text","label":"Address of Nominee: Present address","options":[],"required":true,"pdf_field":""},{"help":"Enter permanent address or leave blank if same as present.","type":"text","label":"Permanent address (if left blank, will be construed as being same as Present Address)","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account holder name for nominee.","type":"text","label":"Bank Account Details of Nominee: Name of Account holder","options":[],"required":false,"pdf_field":""},{"help":"Enter bank name and branch for nominee.","type":"text","label":"Bank Name & Branch","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number for nominee.","type":"text","label":"Bank Account Number","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC code for nominee.","type":"text","label":"IFS Code","options":[],"required":false,"pdf_field":""},{"help":"Provide authorized person details if nominee is minor.","type":"text","label":"Authorized person details (in case nominee is a minor)","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer/owner"},{"title":"Declaration by Proposer","fields":[{"help":"Sign the form; affix stamp if juridical person.","type":"signature","label":"Signature of the Proposer(s) (Affix stamp, where proposer is a juridical person)","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing.","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing.","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer/owner"},{"title":"For Intermediary Use Only","fields":[{"help":"Enter intermediary's name.","type":"text","label":"Name of Insurance Agent/POSP/Specified Person of the Corporate Agent/Authorized Person of the Broker/IMF","options":[],"required":true,"pdf_field":""},{"help":"Enter intermediary code.","type":"text","label":"Intermediary’s Code","options":[],"required":true,"pdf_field":""},{"help":"Intermediary to sign here.","type":"signature","label":"Intermediary’s Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"intermediary"}],"deadlines":[],"applies_to":"Third Party Long Term Two Wheeler Insurance Policy - 5 Years","attachments":["Copies of R.C. & Fitness Certificate","Policy copy of existing CPA Cover or Personal Accident Cover if applicable","Annexure with GSTIN details if more than one GSTIN"],"declarations":["All statements and information provided are complete and accurate with no material facts withheld.","If misrepresentation or suppression of material facts is found, the policy may be void and premium forfeited.","The proposer agrees to assist the insurer with records and information to address anti-financial crime practices.","Premium is paid from legitimate sources and insurer may verify source of funds and reject or terminate policy if otherwise.","Consent is given to receive policy and service communications electronically and for processing of personal data.","Consent is given for insurer to access CKYC records for verification and communication.","The insurer reserves the right to reject or terminate the contract if proposer or associated persons are named in sanctions lists.","KYC records are current and proposer will inform insurer of any changes."],"dropped_labels":10},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"grievance","channel":"email","value":"GCIcare@generalicentral.com","label":"HELPLINE Email","level":1,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"atrix given below.\nLEVEL 1\nYou Can Call On Our HELPLINE\n1800-220-233 / 1860-500-3333 / 022-67837800\nOR\nSEND US AN EMAIL\nGCIcare@generalicentral.com\nOur senior citizen policyholders can avail priority support by choosing the valid option from the helpline menu or writ","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-220-233 / 1860-500-3333 / 022-67837800","label":"HELPLINE","level":1,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"may have. You can escalate your concerns as per the\nescalation matrix given below.\nLEVEL 1\nYou Can Call On Our HELPLINE\n1800-220-233 / 1860-500-3333 / 022-67837800\nOR\nSEND US AN EMAIL\nGCIcare@generalicentral.com\nOur senior citizen policyholders can avail priority support by choosing","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Generali Central Insurance Company Ltd.\nUnit No. 301, 3rd Floor Part, Building No. 8,\nMindspace IT/ITES SEZ, MIDC Industrial Area,\nAiravali, Navi Mumbai,\nThane District – 400 708.","label":"Corporate Grievance Redressal Officer (GRO) Address","level":2,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"ON\n+91-79001 97777\nOR\nSend your complaint to our Corporate Grievance Redressal Officer\nMr. Hari Shankar Mishra\nADDRESS\nGenerali Central Insurance Company Ltd.\nUnit No. 301, 3\nrd\nFloor Part, Building No. 8,\nMindspace IT/ITES SEZ, MIDC Industrial Area,\nAiravali, Navi Mumbai,\nThane District – 400 708.\nLEVEL 3\nIf you are still not satisfied with the solution provided, you can email\nour CEO’s office.\nEMAIL OUR CEO’s OFF","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"GCIGRO@generalicentral.com","label":"Corporate Grievance Redressal Officer (GRO) Email","level":2,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"solution provided to you does not meet your expectations,\nyou can write directly to our Corporate GRO.\nSEND US AN EMAIL\nGCIGRO@generalicentral.com\nOR\nCALL US ON\n+91-79001 97777\nOR\nSend your complaint to our Corporate Grievance Redressal Officer\nMr. Hari Shankar Mish","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"+91-79001 97777","label":"Corporate Grievance Redressal Officer (GRO) Phone","level":2,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/customer-service/grievance-redressal","quote":"ur expectations,\nyou can write directly to our Corporate GRO.\nSEND US AN EMAIL\nGCIGRO@generalicentral.com\nOR\nCALL US ON\n+91-79001 97777\nOR\nSend your complaint to our Corporate Grievance Redressal Officer\nMr. Hari Shankar Mishra\nADDRESS\nGenerali Central In","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/generali-central-insurance/2770-third-party-long-term-two-wheeler-insurance-policy-5-years-proposal-form"}