The New India Assurance Company Limited
Regd. & Head Office: New India Assurance Building, 87, M.G. Road, Fort, Mumbai -400001

             PROPOSAL FORM FOR PRODUCT LIABILITY INSURANCE  
Liability of the company does not commence until the proposal has been accepted and the Premium paid

 1.Name of the Proposer (in full)
   Names of Subsidiaries & Associate Cos. (in full)
 2.Registered Address of the Proposer
   Registered Address of the Subsidiaries & Associate Cos.
   Please state whether cover required for subsidiary &
   Associate Cos.
 3.Business address of the proposer
 4.Location from where distribution is effected 
 5.How long have you been in the business?
 6.Do you manufacture the complete product? If not,
    what components/parts are purchased by you?
 7.Can the date of manufacture of each product be identified 
     by the factory number stamped on it?
 8.Do you have any assets and/or representation and/or any 
   domiciled operation and/or activities and/or association 
   (Financial/Technical or otherwise) in USA/Canada
   and other foreign countries.
  9. Are you affiliated in any manner with any of your 
     suppliers and distributors
  10. Please give full description of the following for the last 
        three years:
(a)	Year
(b)	Goods manufactured and estimated turnover
(c)	Goods sold or supplied and estimated turnover
(d)	Goods repaired, serviced, tested and processed
and  estimated turnover
     (Please attach leaflets, brochures and any other literature)
   11.Please furnish details of products to be considered for 
        insurance which are manufactured and/or designed-
(a)	Name of the product:
(b)	Principal component:
(c)	Annual Units produced:
(d)	Annual turnover:
(e)	How long has it been in the market?
(f)	Expected life of use:
(g)	Intended use:
(h)	Intended customer/ultimate user:
(i)	Warranties as to use:
(j)	Technical know-how/collaboration:
   12. Do you have Research & Development Dept.?
   13. Please specify any products which are inflammable/
         explosive, dangerous, radioactive, harmful, to health,
         poisonous by themselves or any combination with others
         if so, please give full details and state what precautions 
         are taken
   14.Please state whether goods sold are supplied subject to 
        disclaimer notice, and if so, please give full text, particulars
        of such disclaimer notice
   15.Please furnish particulars of new products to be marketed 
        during the next 12 months.
   16. Please furnish details and list of products discontinued or 
        recalled or withdrawn during the last five years
   17.Please elaborate complaints, incidents/accident reporting
        system in your organization
   18.Please give details of checks or examinations or controls 
        including batch control and testing carried out or effected 
        to discover possible defects or errors in products
   19.Do your products comply with standards like ISI or
        any other Standards?
   20.Have your products ever been subject to any enquiry
       or investigation by any Government agency, concerning 
       the efficiency/adequacy or labeling, hazardous contents or 
       safety?
   21.What is the failure rate of each product after hand over?
   22.Do you issue guarantees and/or warranties to purchasers?
        If so, for what period do you guarantee and/or warrant your
        Product?
   23. Particulars regarding directions for use:
(a)	Is it printing on container or product?
(b)	Is it by separate leaflet or brochure?
(c)	Is the hazard warning clearly shown?
   24. Please furnish claims history for the last three years in 
         the following format:
(a)	Year                                  :
(b)	No. of claims                      :
(c)	Total Amount Paid              :
Bodily injury                      :              Rs.
   	   Property Damage               :              Rs.	        
             Cost of defence action         :              Rs.
         (d) Total amt. of pending claims :             Rs.
               Bodily injury 		     :		Rs.  	
               Property Damage                :              Rs.
               Cost of defence action         :               Rs.
    25.Are you aware of any incidents, conditions, defects,
         circumstances or suspected defects which may result 
         in claim?
     26.Have your proposal or renewal been declined or premium 
          increased, special terms imposed by any Insurer? If so,
        please give particulars:
     27.Please indicate the limit of indemnity required for domestic sales:
(a)	Any one accident
(b)	Aggregate during the policy period
     28.Please indicate Voluntary Excess for each claim (in addition to
          Compulsory Excess) you are willing to bear
     29. Please quantify sales turnover product wise for the last 3 years 
          as under:
(a)	Domestic
(b)	USA/Canada
(c)	 Other countries including non-OCED countries
     30.How long have you been exporting to the following countries
          and do you require cover for export to these countries?
(a)	USA/Canada
(b)	OECD countries
(c)	Other countries including non-OECD countries
 (Cover for exports will be granted only if domestic turnover is covered)
      31. Do you require “Limited Vendor’s Endorsement”?
           (Please enclose a copy of the contract with the Vendors and 
             give the names to each product of export of such countries)
       32. Do you comply with USA/Canadian State/Federal Laws/
              Standards applicable to each product of export of such countries
      33.Please give details of any power of attorney to Assets in USA/Canada
      34. Policy Period:                      		From 12-00 midnight of  -----------   
 							to 12-00 midnight of ---------------

         I/We desire to effect an Insurance in terms of the Product Liability Policy of the New India Assurance Company Ltd against the limits of indemnity specified above. I/We hereby declare that all statutory provisions relating to my/our business proposed for Insurance are complied with. I/We further declare that all the above statements and particulars are true, and I/We have not omitted, suppressed, misrepresented or misstated any material fact and I/We agree that this declaration shall be the basis of the contract between me/us and the Company and be incorporated therein.

Place:

Date:							 Signature of the Proposer