THE NEW INDIA ASSURANCE COMPANY LIMITED 
87. M.G.ROAD, FORT,  MUMBAI  -  400 001.

                            PROPOSAL FOR STANDARD FIRE & SPECIAL PERILS POLICY 

Acceptance of this proposal is subject to the rates & regulations of Tariff Advisory Committee’s Tariff. The property is not covered until the risk is accepted and premium paid.

Divisional Office Address & Code

Development Officer’s Name & Code  		
Agent’s Name & Code 		

DETAILS ABOUT PROPOSER

  1. Name of Proposer    
                        		
  2. Address of Proposer including Phone, Fax, E-mail & Pincode
		
  3. Business of Proposer              
           		
  4. Paid up Capital of the Firm	
	
5.Policy to be Issued in favour of   
(List out all the parties who have insurable interest including the Financial Institutions)		
6. Location to be covered  - (Full Postal Address with Pincode)         
                            		
7. Period of Insurance	From                               To
	
8.Would you like to delete these perils from the basic cover?	  a.  Flood, Cyclone, group of   
     perils  	Yes / No	
	b.	Riot, Strike, Malicious and
     Terrorism Damage	Yes / No	
 9. Would you like to cover the following along with your buildings?	Plinth & Foundation
	Yes / No	

10. Add-On Covers Required as under
		
Architects, Surveyors & Consulting Engineers Fees (in excess of 3% of the claim amount)	Yes / No	
Debris Removal (in excess of 1% of claim amount)	Yes / No	
Deterioration of Stocks in cold storage premises due to failure of Electrical Supply at terminal ends of Electric Service Feeders	Yes / No	
Forest Fire	Yes / No	
Impact damage due to insured’s own vehicles	Yes / No	
Spontaneous Combustion	Yes / No	
Omission to Insure additions	Yes / No	
Earthquake  (Fire & Shock)	Yes / No	
                        
 11. Whether you have insured the same property with any other Insurance Company with identical coverage. (Give details) 		

 12. Whether Insurance cover was declined by any other Company or imposed any Special Conditions (Give details) 		

13.Premium / Incurred Claim details for the past three preceding  policy periods	Premium	Incurred Claims	

			

DETAILS ABOUT PROPOSER’S BUSINESS COVERED AT THE LOCATION

14.The Insured property is
		
Dwellings, Offices, Shops, Hotels etc	Yes / No	
Industrial / Manufacturing Risks	Yes / No	
Storages outside Industrial Manufacturing Risks	Yes / No	
Tanks / Gas Holders outside Industrial Manufacturing Risks	Yes / No	
Utilities located outside Industrial Manufacturing Risks	Yes / No	

 15.If used as Shop, please declare whether the stocks stored include any stocks appearing in the list given below.  If yes, whether the value of such stocks exceed 5% of total value of stocks 	Yes / No	

1.Celluloid Goods, 2.Coir Loose, 3.Crackers & Fire Works, 4.Explosives of any kind, 5.Hay / Straw, 6.Hemp, 7.Jute Loose, 8.Matches, 9.Methylated Spirit, 10.Nitro-Cellulose Plastics, 11.Oils / Ether / Industrial Solvents and other inflammable liquids flashing at and below 32 Deg.C (Closed Cup test), 12.Paints with inflammable base having flash point below 32 Deg.C (Closed Cup test) - other than in sealed tins or drums, 13.Varnishes having a Flash point below 32 Deg.C (Closed Cup test) - other than in sealed tins or drums,14.Disinfectant liquids and liquid insecticides - other than in sealed tins or drums,15.Vegetable fibres of any kind including Rayon Fibre.  	

 16.If used as warehouse / godown (not located in a manufacturing unit) please give the list of goods stored 	

 17.If used as an Industrial Manufacturing unit, state the details of products manufactured at the location proposed.                    	
	
 18. If used as an Industrial Manufacturing unit, please state whether the factory is working or silent?                     	

19.Fire Extinguishing Appliances installed 
	Please Tick in the box below	
Portable Extinguishers			
Trailer Pumps			
Fire Engine			
Hydrant System			
Sprinkler System			
Fixed Water Spray System			

 20. The basis proposed for   insurance  (Building / Machinery / Furniture Fixtures & Fittings)
	
 Market Value basis	Yes /No	
Reinstatement Value Basis	Yes /No	

21.Construction Details
	
a	Please state material used	i. Walls	
		ii. Floor	
		iii. Roof	
b	Height of the Building
	________ Meters          _________Floors	
c	Age of Building	Less than 5 Years              5 - 10 Years           
10 – 20 Years                      Above 20 Years    	
Note:
Buildings having walls and/ or roofs of wooden planks/thatched leaves and/or grass/hay of any kind/bamboo/plastic cloth/asphalt cloth/canvas/tarpaulin and the like are treated as “Kutcha” construction.	

22.Building wise values (Please include the Kutcha buildings also in this list and give individual values against such buildings)
	
 Description
Of Block 	Amount in Rs	
	Age
Yrs	Height
Mts	Construction	Building including plinth	Machinery & Accessories	F&F, office 
and other
equipments	Stocks and Stocks in process**	Other Property  to be insured specifically	Total	

										

										

										
Total										
Note
** Indicates those stocks which are covered on normal basis and do not fall under Serial No.23 A, B, C and D below	

23.Special Coverage for Stocks only
Please Tick in the box below and give the amount to be insured against each	
A. On Floater Basis   

Stocks at various locations (Process blocks, warehouses / godowns and /or in open etc.,) can be covered on floater basis under single Sum Insured.	
Locations (Postal Address with Pincode)		Amount Rs.	

		 	

B. On Declaration Basis   

Stocks which fluctuate in value can be covered on (monthly) declaration basis. 	
Locations (Postal Address with Pincode)		Amount Rs.	

		 	
Note: 
1.Minimum Sum Insured per policy should be Rs.1 Crore, and policy not to be issued on short period basis
2.Stocks in process & stocks stored at Railway sidings cannot be covered	

C. On Floater Declaration Basis   

Stocks which fluctuate in value as well as stored at various locations under single Sum Insured can be covered on (monthly) floater declaration basis. 	
Locations (Postal Address with Pincode)		Amount Rs.	

		 	
Note: 
1.Minimum Sum Insured should be Rs. 2 Crores
2.Stocks in process & stocks stored at Railway sidings cannot be covered	

D. Stocks stored in open  (located outside the factory compound)
   
     Details of stocks stored in the open	
Locations (Postal Address with Pincode)		Amount Rs.	

			

E. Tank Farm and Gas holders  (located outside the factory compound)
   
     Details of stocks stored	
Locations (Postal Address with Pincode)		Amount Rs.	

			

25. Add-On Covers	Clause Code	Risk Code	Rate
Code	Rate	Amount to be Insured/Percentage
 wherever applicable	
Architects, Surveyors & Consulting Engineer’s Fees						
Debris Removal						
Spontaneous Combustion						
Omission to Insure additions (%)						

Declaration by Insured

I/ We hereby declare that the statements made by me / us in this Proposal Form are true to the best of my / our knowledge and belief and I / We hereby agree that this declaration shall form the basis of the contract between me / us and the “THE NEW INDIA ASSURANCE COMPANT LIMITED”. 

If any additions or alterations are carried out in the risk proposed after the submission of this proposal form then the same would be conveyed to the insurers immediately.
	
Date	
	Place		
Recommendations of Development Officer / Agent	

	Signature of Proposer		
 Prohibition of Rebates (Section 41 of the Insurance Act)

1.  No person shall allow or offer to allow either directly or indirectly as inducement to any person to take out renew or continue an insurance in respect of any kind of risk relating to lives or property in India any rebate of the whole or part of the commission payable any rebates as 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 Insure.  Provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be acceptance of are take of premium within the meaning of this section if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is `Bonafide’ insurance agent employed by the Insurer.

2.  Any person making default in complying with the provision of this section shall be punishable with fine which may extend to five hundred rupees only.