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DECLARATION
I/We hereby declare and warrant that the above statements are true and complete in all respects and that there is no other information which is relevant to my application for insurance for me or the person to be insured that has not been disclosed to you. I/We and/or the person to be insured agree that this proposal and the declarations shall be the basis of the contract between me/us and/or the person to be insured and Universal Sompo General Insurance Co Ltd and I/We and/or the person to be insured agree to accept a policy, subject to the conditions prescribed by Universal Sompo General Insurance Co. Ltd. and to pay premium. I/We and/or the person to be insured hereby consent and authorize you to seek medical information from any Hospital/Medical Practitioner from which or whom I/We and/or the person to be insured have at any time sought or shall seek medical attention concering any disease, sickness, ailment, or injury which affects my/our and/or the person to be insured's physical or mental health.

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SECTION 41 OF INSURANCE ACT, 1938

No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer.

Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to Five hundred rupees.

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Regd & Corp Office : Universal Sompo General Insurance Co Ltd. Unit No 401, 4th Floor,Sangam Complex, 127,
Andheri Kurla Road,Andheri (E), Mumbai- 400059. Tel : 022-29211800, Fax : 022-29211844
Insurance is the subject matter of solicitation. IRDA Registration Number - 134. Control Number -ENG/WBHP/CHG/150/Mar2013.
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