New India Building, 87, M.G. Road, Fort, Mumbai - 400 001 

                                                  Jewellers’ Block Insurance

Please reply in full to all the following questions. If the answer to any question is none state ‘NONE’
1.	(a)	Name of the Proposer  (in full)-----------------------------------------

(b)	Address to which all communications
should be sent	             ---------------------------------------------

(c)	State Address of all premises where
insured’s business is carried on (if more than one,
please attach a statement. The floors on which
premises are situated may also be specified)-------------------------

(d)	Since when Established	----------------------------------------------

2.	NATURE OF YOUR BUSINESS                  	 					(a) Wholesale
(b) Retail
(c) Manufacturing
(d) Pawn broking

NOTE : Cover is NOT meant for those Establishments, whose work is predominantly manufacturing and/or pawn broking.

3.	(a)	(i)	Do you have a safe in all your premises
(ii)	Give the Safe Maker’s name, cost,
when purchased (state whether new or
secondhand)
(iii)	Specify-(1) Height (2) Width
(3) Depth (4) Weight of safe

(iv)	Address of premises where safe is kept

NOTE : Safe has to be of standard make, otherwise cover would not operate.

(b)	Will the premises be occupied at night by the Proposer

(c)	Will there be a watchman on the insured premise(s).
If yes,specify : - (Answer for all premises)

(i)	Whether he/they is/are your employees and is/are employed
for all the 24 hours of the day
or

(ii)	Whether he/they is/are Common Watchman for the whole
building/locality, if so whether during day time only/Night
Watchman or 24 hours ?
or
(iii)	Whether he/they is/are Watchman employed to guard              			insured’s premises only during day time/night times ?

(d)	Are there any special security features provided. 					If yes, specify the premises-

(i)	built in vaults ?
(ii)	strong rooms ?
(iii)	close circuit T.V. System ?
(iv)      round the clock armed guards with fire arms ?

(e)	Is a burglar alarm system installed or any other special means
of protection adopted ? If so, state what protection.

(f)	Is an inside grill fitted to your Gold and Gems showroom,
Window or is any other protection installed against loss
by window smashing ? If so, state what protection.

(g)	Are  your display windows, protected by Roller Shutter 				outside business hours ?

(h)	How are the doors secured outside business hours ?

(i)	How are the windows protected ?

(j)	How are Skylights, if any, protected ?

4.	window display
State the approximate maximum value of any one article of
jewellery or gem stock which will be displayed in the window
(A pad or tray containing a number of rings or other articles
to be counted as one article).
(give separate answer to each location).
NOTE : Window display out of business hours is not covered.

5.	stock
Amounts showed herein should be on the basis of the cost price.

(a)	What was the average daily total value of your-
(i)	stock during the past 12 months ?
(ii)	cash and currency notes during the past 12 months.

(b)	Will the whole of your stock when on your premises be
kept in safe at night and at all times when the premises
are closed ?

NOTE : We do not cover stocks kept out of the safe after Business
Hours and at Night

6.	losses

(a)	Have you ever sustained a loss or losses ?

(b)	If so, give statement covering past five years with particulars

(c)	Were you insured and if so, give the name of the Insurance
Company and whether they paid the claim in full or a part
thereof with details of year of occurrence, section under which
claim arose, amount of loss, whether paid or outstanding etc.

7.	PROPERTY TO BE INSURED

Sum to be  insured		                                                                    	Valuation basis for Section I, II & III = Cost + 10%

SECTION I

(a)	Property Insured on the premises
(i)	Property insured in display windows	(i)

(ii)	Property Insured in Locked safe on the Premises	(ii)

(iii)	Elsewhere in the Premises	(iii)

(b)	Outside the premises (in custody or in transit or entrusted
to persons as covered under sections II & III)                              (b)

(c)	Cash and Currency Notes	(c)
(d)	Property Insured in Bank Lockers subject to insured 	(d)
maintaining a separate register to record all deposits/
withdrawals in such lockers. Address of the Branch of
the Bank.

SECTION II

Outdoor Risk                                                           Limit for   Any one Loss

(a)	Property excluding cash & currency notes in the custody	(a)
of the insured, his partners, directors, duly constituted
attorneys, sorters of diamonds and his employees.

(b)	Property insured directly entrusted by the insured excluding	(b)
cash and currency notes whilst in the custody of brokers or
agents or cutters or goldsmiths or sorters of diamonds, not
in regular employment of the insured

Separate limits will have to be shown for (a) & (b)
Total of (a) & (b) should not exceed Sec I Sum Insured.

NOTE : 	Proposer to maintain proper records of ‘Jangad Slips’ including
preservation of copies of Jangad slips, serially numbered and
bearing the date.

SECTION III

The Property insured including cash & currency notes whilst in Transit within
India by-

(a)	Regd. Insured Post Parcel (to be insured for 	(a)
maximum permissible value with postal authorities)
Limit for Any One loss not exceeding
Rs. 5 Lacs or 10% of sum Insured under Sec-I,
whichever is lower.

(b)	Air Freight	(b)
(minimum 20% value to be declared to the Airlines)

(c)	Angadia	(c)

Total of (a) (b) & (c) should not exceed Section I Sum Insured.

SECTION IV

(i)	(a)	Furniture Fixtures Fittings including safe at business premises

(b)	Safes at residences.

(ii)	Trade Equipment as per list attached.

NOTE : The sum to be insured on Trade equipments and Office furnitures.
Fixtures & Fittings, Machinery Plant all other contents (except your
stock & goods in trust) represent the full market value thereof.

8.	references :
Unless proposing for renewal, give two references from your trade   (1)
(name & address)                                                                                (2)

9.	OTHER INSURANCE

(a)	Have you been previously insured ? If so, state with whom risks
covered, and for what amount.

(b)	Has any insurer ever cancelled or refused to issue or to continue
any insurance for you ?

(c)	Has any Insurer accepted your proposal on increased rates
and/or imposed any special conditions.

10.	PERIOD OF INSURANCE                      FROM              /   /        TO        /  /

I/We the undersigned, do hereby warrant & declare the truth of all the above statements and that we have not withheld any material information and it is agreed that this form shall be the basis of Contract should policy be issued.

I/We agree that if this Insurance is completed the protection and/or safeguards mentioned above shall not be withdrawn or varied to the detriment of the interests of the Company without their consent.

Date :
Place :                                                                                 ------------------------------			                                                                             Signature of Proposer

The Proposer is known to me/my Agent for_______years and I recommend acceptance of this proposal.

Signature of the Dev. Officer

Date                                                                                                Name-----------
Place                                                                                               Code-----------

PROHIBITION OF REBATES
The following is the copy of Section 41 of the Insurance Act 1938.
1.	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 live or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown in the policy; nor shall any person taking out or renewing continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses of rebates of the Insurer.
2.	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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