8/3/2019 Yeu Cau Bao Hiem o to Normal

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GIY YU CU BO HIM XE TMOTOR VEHICLE INSURANCE PROPOSAL FORM

Ngi yu cu bo him lu phi k khai y , trung thc cc cu hi trong Giy yu cu ny. Giy yu cu ny nh km v l mt b phn

khng tch ri ca hp ng bo him (The Proposer is required to declare information fully and honestly. This Proposal Form shall be enclosed with and be constituted as an integral

part of the relevant insurance policy)

Tn ngi yu cu bo him - ch xe(Proposer):

M s thu (Tax Code):

a ch lin lc (Contact Address):

in thoi (Tel): S Fax (Fax Number):

Thi hn bo him (Insurance Period) T (From): n (To):

Bin s xe (Plate No.): S khung (Chassis No.): S my (Engine No.):

Loi xe (Mark and model): S ch ngi (Seats): Nm sn xut (Years of manufacture):

Xut x (Origin): Xe sn xut trong nc (Domestic) Xe nhp khu (Import)

Mc ch s dng(Purpose of Usage): Xe khng kinh doanh vn ti (Non-transportation) Xe ch hng (Goods transport)

Xe khch (Passenger transport) Xe taxi (Taxi) Khc (Other)

Gi tr thc t ca xe(Curent value):

www.baovietbank.vn

iu kin bo him(Terms and conditions)Trn c s Ngi yu cu bo him c v hiu quy tc bo him nh km (Subject to the Insureds having read and understood the policy wording attached)Theo quy tc bo him xe t ca Tng Cng ty Bo him Bo Vit v quy tc bo him bt buc trch nhim dn s ca ch xe c gii do B Tichnh quy nh(As per Regulations on Motor Vehicle Insurance of BHBV and in accordance with the provisions on Mandatory Insurance of Civil Liabili ties of vehicle owners issued by the Min istryof Finance)

Cam kt ca Ngi yu cu bo him (Undertakings by the Proposer)

Ti/Chng ti xc nhn rng cc thng tin nu trn l y v xc thc theo s hiu bit cao nht ca Ti/Chng ti v ng rng Giy yu cu bohim ny l c s ca hp ng bo him v chp nhn cc iu kin bo him quy nh ti hp ng bo him (I/We hereby certify the above statements arecomplete and true to the best of My/Our knowledge and agree that this Proposal Form shall be the basis of the Insurance policy and accept the insurance as set out in the Insureds Policy)

Ch k Ngi yu cu bo him H v tn Ngy(Signature of Proposer) (Name) (Date)

................................................................................... ................................................................................ ............./.........../............

Chi tit bo him(Details of Insurance)

Thit hi vt cht(Motor vehicle_Physical Damage)

Trch nhim dn s i vi ngi th ba(Civil liabilities of vehicle owners_Third Party Liability)

Tai nn i vi ti x v ngi ngi trn xe(Driver & Passenger Accident)

HMTN v ngi(Limit of liability for body injury)

HMTN v ti sn(Limit of liability for property damage)

Gii hn bi thng/ngi(Limit of indemnity per person)

S ngi (No. of person)

Tng cng(Total)

S tin bo him(Sum Insured)

T l ph(Rate)(Including VAT)

Ph bo him(Premium)

/Ngi(person)

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Hp ng s (Policy Number):...............................................

Sn phm Bo him Xe t do Tng Cng ty Bo him Bo Vit, 35 Hai B Trng, H Ni, Vit Nam cung cp, mi quynli bo him v cc vn c lin quan do Tng Cng ty Bo him Bo Vit chu trch nhim gii quyt. (This product isunderwritten by BaoViet Insurance Corporation, Address: 35 Hai Ba Trung Street, Hanoi, Vietnam. All relevant benefts and issues are undertaken by BaoViet Insurance)

Mu s: BHX-02