The New India Assurance Company Limited
Registered & Head Office : New India Assurance,87,M.G. Road,Fort,Mumbai - 400 001

PROPOSAL FORM FOR INSURANCE UNDER PUBLIC LIABILITY INSURANCE ACT 1991

1. Name of the Proposer/ Owner in full (see note) _____________________
2. Address ____________________________________________________
_____________________________________________________________
_______________________________PIN___________________________
3. Business ____________________________________________________
4. Paid up capital (See Note) ______________________________________
5. List of hazardous substances handled and Group
(See Note)__________________________________________________
6. Details of all accidents during past 3 years and
compensation paid/claimed but not yet paid ________________________
7. Estimated annual turnover (See Note)
(a) Proposed Insurance Year
(b) Previous Year

8.Number of (a) Workmen Employees ________________
(b) Other Employees (See note)___________
10. Limit of Indemnity required in respect of Any one
accident __________________________________________________

Policy period required From AM/PM
To midnight of....___________
I/We hereby declare that (a) all statutory provisions relating to my/our business proposed for insurance are complied with, (b) the above statements and particulars are true. (c) I/we have not omitted, suppressed, misrepresented or misstated any material fact and (d) 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

Note to items :
1. Owner means a person who owns \, or has control cover handling any hazardous substance at the time of accident and includes-
(i) in the case of a firm, any of its partners
(ii) in the case of an association, any of its members and
(iii) in the case of a company, any of its directors, managers, secretaries or other officers who is directly in charge of, and is responsible to the company for the conduct of the business of the company.
4. Paid up Capital means in the case of an owner not being a company, the market value of all assets and stocks of the undertaking on the date of contract of insurance.
5. Hazardous Substances and Group means the items listed and grouped under Environment (protection) Act 1986 and the Rules framed there under.
7. Turnover shall mean-
(i) Manufacturing units-Annual Gross Sales of all goods including all levies and taxes.
(ii) Godown-warehouse owners-Total Annual rental receipts.
(iii) Transport operators-Total annual freight receipts.
(iv) Others-Total annual gross receipts.
8. ‘Workmen Employee’ shall mean such employees within the definition of “Workman”under the workmen’s Compensation Act, 1923.
There is separate policy covering LEGAL LIABILITY other than the Act Liability proposed for insurance in this proposal details of which can be obtained from the Company’s offices.

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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