THE NEW INDIA ASSURANCE COMPANY LIMITED
Regd. & Head Office:New India Assurance Building,87,Mahatma Gandhi Road,Fort,
Mumbai 400 001

PROPOSAL FORM FOR BURGLARY AND HOUSE-BREAKING INSURANCE
(BUSINESS PREMISES)

CODE

DEV OFFICER AGENT

ADDRESS OF ISSUING OFFICE FOR OFFICE USE ONLY

ACCEPTED BY _______________
DATE OF TIME _______________
RATE _______________________
REMARKS ___________________
POLICY NO.__________________
COLLECTION/SCROLL NO._____

______________________________________________________________
NOTE : PLEASE ANSWER EVERY QUESTION AND FULLY

1. (a) Name and address of the Proposer
in full (BLOCK LETTERS) __________________________

(b) Name of the Financial Institution/s
(if any financial interest is involved) __________________________

(c) Nature of Trade or Business __________________________

2. Address of the premises to be insured __________________________

3. (a) Whether Warehouse, godown Shop
or Office ? __________________________

(b) How long have you been an occupant
Of premises. _________________________

(c) Are you the sole occupant ? __________________________

(d) If not, who are other occupants ? __________________________

4. What materials are used for construction ?
e.g. Concrete, Bricks, Iron Sheet or
Timber etc.

(a) Walls __________________________

(b) Roof __________________________

(c) Floor __________________________

5. What protection is provided to ;

(a) Doors : __________________________

(b) Windows __________________________

(c) Skylights, Ventilators, Exhaust
Fans, Lights, Airconditioners
Trap Doors ? __________________________

(d) Any other opening __________________________

(e) Mention any special precautions
you have adopted for safeguarding
your property __________________________

6. (a) Are the premises occupied by you at
night ? if not, by whom ? __________________________

(b) Will the premises be guarded by
Watchman ? __________________________

(c) Will the premises at any time be
left un-occupied ? __________________________

(d) If so, how often and for how long ? ___________________________

7. (a) Are all valuables secured in safe(s)
outside business hours ? ___________________________

(b) Give (1) Maker’s Name (2) Height
(3) Width (4) Depth and
(5) Weight of Safe(s), ___________________________

(c) How many keys are there to the
Safe(s) and with whom are they
kept ? Can the safe(s) be opened
by a single key or by a combination
of two or more keys ? __________________________

8. (a) Are Stock and Sales books
maintained ? __________________________

(b) How frequently are these entered ? _________________________

(c) How after is stock taken ? __________________________

(d) Where are these books kept outside
Business hours ? __________________________

9. (a) Have any premises occupied by
you been entered by thieves ? __________________________

(b) If so, give full particulars stating when
and how access was obtained and the
extent of the loss. _________________________

(c) What precautions have been adopted
to prevent such a recurrence ? _________________________

10. Is the risk currently insured against
Burglary ? If so, _________________________

(a) The name of Insurance Company _________________________

(b) Policy No. _________________________

(c) Period _________________________

11. Has any Company in respect of your
Burglary Insurance : _________________________

(a) Declined your proposal ? _________________________

(b) Cancelled or refused to renew your policy? __________________

(c) Accepted your proposal on Special ¬¬¬¬¬¬¬¬
terms and conditions ? _________________________

12. Have you ever claimed upon any Company
for loss by Burglary or House breaking ?
If so, give details _________________________

13. Amount for which contents are currently
Insured against fire and name of the
Company _________________________

14. Give full description of contents (i.e. the
Property to be insured) of the premises _________________________

15. Do you need cover against Riot and
Strike, terrorist activities on payment
Of additional premium ? _________________________

16. PROPERTY TO BE INSURED (give full
Details ) SUM TO BE INSURED (Rs.)

(a) Stock-in-Trade (as described in
Item 14 above)

(b) Goods held by the Proposer in
Trust or on commission for which
he is responsible.

(c) Furniture, Fixtures, Fittings,
Utensils and Appliances in trade.

(d) Coins and/or Currency Notes in
Locked safe

(e) Others (to be specified) __________________________
Total Rs.

N.B. To obtain full indemnity it is necessary to insure for the full value of the property in the premises.

17. From ______________________To ______________________________

I/We do hereby declare that the above statements and answer are true and that I/we have not withhold any information whatsoever regarding the Proposal. I/We agree that this proposal and declaration shall be the basis of the contract between me/us and The New India Assurance Co., Ltd. whose Policy for the Insurance proposed is acceptable to me/us. I/we undertake to exercise all ordinary and reasonable precautions for safety of the property as if it were uninsured.

Place :

Date : Signature of Proposer

Note : 1. The liability of the Company does not commence until the proposal
has been accepted by the Company and the premium paid.

2. Premium will be quoted on application.

DEVELOPMENT OF OFFICER’S REPORT

The Proposer is known to me/my agent for ________years and I recommended acceptance of this proposal.

Date :

Place : Signature of Dev. Officer

Name and Code No.

PROHIBITION OF REBATE

Section 41 of the 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 the 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 prospectus or tables of the insurers.

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