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

HOUSEHOLDER’S INSURANCE

PROPOSAL FORM CUM SCHEDULE ATTACHED TO & FORMING PART OF POLICY NO.

AGENCY PERIOD OF INSURNACE FROM :
TO :
INSURED :
:
1. NAME OF PROPOSER IN FULL

2. RESIDENTIAL ADDRESS

3. OCCUPATION

SECTION NO . DESCRIPTION OF PROPERTY SUM RATES PREMIUM
INSURED (per mille) (for the use
of the company) Rs.

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I (A)BUILDING(OFCLASS-ACONTRUCTIONONLY) 0.50
FIRE AND (B)CONTENTS : (Excluding Jewellery/Valuables) Belonging to the proposer and members of his family permanently
ALLIED PERILS Residing with him.................... 0.50

II CONTENTS :
BURGLARY AND All contents in the Premises stated at the address above 2.40
HOUSEBREAKING
INCLUDING NOTE : Insurance on contents should be for value equivalent to
LARCENY OR the value mentioned under item I (B) above
THEFT

III JEWELLERY & VALUABLES :
ALL RISKS Description of jewellery and valuables-value........ 10.00

IV
PLATE GLASS Description of plate glass and its value.................... 10.00

V Description of all Electrical, Electronic and Year of Make Values 2.50
BREAKDOWN Mechanical Appliances, Apparatuses or
OF DOMESTIC Gadgets belonging to the proposer
APPLIANCES Total...............
VI
T.V. SET Name of Manufacturer Make Model Year of Value 10.00
Make

VII Make & name of Year of mfgr. Frame Value including
PEDAL Manufacturer No. accessories
CYCLES 1. Rs.
2. Rs.
3. Rs
4. . --------------------------
Rs. 20.00
-------------------------
VIII Details of Personal Baggages, Personal effects and other articles carried
BAGGAGE (During the period of Travel anywhere in India).......... 7.50
INSURANCE Total...............Value

IX Name Age Occupation Relationship Details of Table Name of As per
PERSONAL with Existing opted Assignee Schedule ACCIDENT Proposer infirmity/ & relation- disability ship
NOTE : (i) For Table of Benefit sheet information sheet.
(ii) for assignment of benefit in case of death (Please see below)

X (A) Public Liability 0.50
PUBLIC (B) W.C. Liability for domestic servants as per
tariff

Note : 1. The liability of the company does not commence until the proposal
has been accepted by the company and the full premium paid. 2. If space found is insufficient please attach separate sheets for details
TOTAL PREMIUM Rs.
Less : Discount for
. covering more than
4 Sections ..........% Rs.
Service Tax 5% Rs
-------------------.
Rs .
I/we hereby declare the particulars contained herein are true and correct and that no material fact has been withheld,misstated or misrepresented and also that this Proposal-cum-Schedule forming part of the company's standard policy shall be the basis of the contract between me/us and the company.I/we further declare that the sum insured herein represents the full value of the property described herein.

PLACE :

DATE : Signature of Proposer